 |
Annali di Stomatologia | 2026; 17(3): 564-574 ISSN 1971-1441 | DOI: 10.59987/ads/2026.3.564-574 Articles |
Strategies for microbial biofilm control and gingival inflammation management during orthodontic treatment: a critical appraisal of recent clinical evidence
Article History
Received: May 18, 2026
Accepted: July 20, 2026
Published: July 30, 2026
Abstract
Aim
Dental plaque is the primary etiological factor for gingival and periodontal diseases, and orthodontic appliances often complicate plaque control. Brackets, archwires, ligatures, aligners, and retainers may create appliance-specific hygiene challenges. This narrative review critically appraises recent clinical evidence on oral hygiene strategies and adjunctive tools to control plaque accumulation and maintain gingival health during orthodontic treatment.
Materials and Methods
A structured literature search was performed in PubMed, Embase, and Web of Science for studies published between 2015 and 2025, focusing on oral hygiene interventions, adjunctive devices, and appliance-related plaque-control outcomes in orthodontic patients. After screening and eligibility assessment, 16 studies were retained for narrative synthesis.
Results
Evidence comparing manual and powered toothbrushing was heterogeneous. Powered toothbrushes, interactive/app-supported devices, and microcurrent-emitting brushes showed advantages in some trials, whereas other studies found no clinically meaningful difference when manual technique and adherence were adequate. Chemical adjuncts and dentifrices, including chlorhexidine and propolis-based regimens, showed short-term benefits in selected settings. Still, their use should be individualized and interpreted in light of study heterogeneity and possible adverse effects. Orthodontic-specific brushing techniques, selected brush designs, and interdental aids may improve plaque control. Clear aligner therapy was generally associated with more favorable hygiene conditions than fixed appliances, while retainer design influenced plaque accumulation during retention.
Conclusion
Effective plaque control during orthodontic treatment requires individualized protocols that consider appliance type, patient age, dexterity, adherence, and baseline periodontal risk. No single device can be recommended universally. Structured hygiene education, reinforcement over time, and regular monitoring of plaque and gingival indices remain central to prevention.
Keywords: Orthodontic appliances; dental plaque; plaque index; gingival index; gingivitis; oral hygiene; chlorhexidine mouthrinse; powered toothbrush; clear aligners; fixed appliances.
1. Introduction
Dental plaque is a structured microbial biofilm that adheres to tooth surfaces and gingival tissues and represents a central etiological factor in plaque-induced gingivitis and periodontal disease [1]. In orthodontic patients, this biofilm-centered process is clinically relevant because appliances may alter local ecology, create retentive niches, and reduce the practical effectiveness of routine oral hygiene [2–3].
Fixed orthodontic appliances are particularly challenging because brackets, bands, archwires, elastomeric ligatures, and auxiliary components increase the number of plaque-retentive surfaces, making mechanical plaque removal more difficult. Longitudinal clinical evidence has shown that fixed appliances may be associated with unfavorable changes in periodontal variables and oral microbiology when plaque control is inadequate [3–4,38].
Clinical monitoring generally relies on standardized indices. The Plaque Index (PI) and Gingival Index (GI) remain widely used measures for assessing oral hygiene and gingival inflammation, while bleeding indices provide clinically sensitive information on gingival inflammatory activity around interdental and papillary areas [5–6]. These indices are particularly useful during orthodontic treatment because inflammatory changes may emerge rapidly when plaque accumulates around appliances.
Mechanical plaque removal remains the foundation of prevention, but its effectiveness depends on brushing technique, brushing time, motivation, manual dexterity, age, and appliance type. Systematic evidence on self-performed mechanical plaque removal supports the importance of technique and adherence rather than device selection alone [7,25].
Chemical adjuncts, mouthrinses, dentifrices, and interdental aids may provide additional benefit in selected orthodontic patients, but the clinical evidence is heterogeneous and should be interpreted cautiously. Previous systematic evidence on mouthwashes in orthodontic patients suggests that adjunctive agents may reduce cariogenic biofilm and gingival inflammation. However, effects vary by formulation, comparator, follow-up duration, and outcome measure [8,26].
Therefore, this narrative review aims to critically appraise recent clinical evidence on oral hygiene strategies for patients undergoing orthodontic treatment, with particular attention to plaque control, gingival inflammation, bleeding-related outcomes, appliance type, and the clinical limits of the available evidence.
2. Materials and Methods
This narrative review was based on a structured literature search to identify clinical evidence on oral hygiene strategies for plaque control and gingival health during orthodontic treatment. The review was planned as a qualitative critical appraisal rather than a quantitative meta-analysis.
2.1 Data sources and search strategy
The electronic databases PubMed, Embase, and Web of Science were searched for articles published between 2015 and 2025. The search strategy combined free-text terms related to dental plaque and clinical indices (e.g., “dental plaque”, “bacterial plaque”, “plaque index”, “gingival index”, “bleeding index”, “MPBI”) with orthodontic-related terms (e.g., “orthodontic treatment”, “fixed appliances”, “brackets”, “archwires”, “clear aligners”, “retainers”) and oral-hygiene intervention terms (e.g., “manual toothbrush”, “powered toothbrush”, “mouthrinse”, “chlorhexidine”, “dentifrice”, “interdental floss”, “water flossing”).
2.2 Study selection
The database search yielded 478 records. After duplicate removal (n = 77), records were screened by title and abstract (n = 401). Full texts were assessed for eligibility (n = 31), and 16 studies were included in the final narrative synthesis after exclusion of reports that did not involve orthodontic patients, were review articles rather than primary clinical studies, focused mainly on in vitro/material outcomes, or did not report relevant plaque/gingival clinical outcomes.
2.3 Eligibility criteria
Studies were considered eligible if they: (i) involved human participants undergoing orthodontic treatment or orthodontic retention; (ii) evaluated oral-hygiene interventions, adjunctive devices, chemical adjuncts, dentifrices, appliance type, or retainer-related plaque-control outcomes; (iii) reported clinical outcomes related to plaque and gingival health, such as PI, GI, visible plaque index (VPI), gingival bleeding index (GBI), MPBI, or comparable measures; (iv) were published in English between 2015 and 2025; and (v) were available as full-text articles. Eligible study designs included randomized controlled trials, crossover trials, controlled experimental studies, and observational or comparative clinical studies. Reviews, editorials, in vitro and animal studies, non-English publications, and studies published before 2015 were excluded from the included-study table, although selected earlier or review-level sources were retained as background references where appropriate.
2.4 Data extraction and synthesis
For each included study, the following information was extracted: author and year, study design, sample size, participant characteristics, type of orthodontic appliance or treatment phase, intervention/comparator, and main reported outcomes. Findings were summarized qualitatively and organized according to intervention domain: manual/powered toothbrushing, chemical adjuncts and dentifrices, brush design and technique, interdental aids, and appliance- or retention-related factors.
3. Results
A structured eligibility check was applied to all retrieved records to ensure that included studies involved orthodontic patients or orthodontic retention, evaluated clinically relevant oral hygiene strategies or appliance-related plaque control factors, and reported plaque or gingival outcomes. The search identified 478 records; after screening and full-text eligibility assessment, 16 studies were included in the final narrative synthesis. The selection process is summarized in the PRISMA-style flow diagram (Figure 1). Table 1 summarizes the characteristics and main outcomes of the included studies.
| Author (Year) | Study design | Sample | Age | Gender | Treatment /Intervention | Outcomes |
|---|---|---|---|---|---|---|
| Lotif et al. (2022) [9] | Randomized, double-blind clinical trial | 42 orthodontic patients | Not stated in table source | Not stated | Fluoridated Brazilian red propolis dentifrice vs fluoridated common dentifrice | BRP dentifrice showed antimicrobial activity against Lactobacillus spp. and decreased VPI over 4 weeks |
| Furtado Junior et al. (2020) [10] | Randomized, double-blind clinical trial | 92 adolescents under orthodontic treatment | Adolescents | Not stated | Fluoride dentifrice vs fluoride dentifrice with Brazilian red propolis | Both groups reduced GBI; BRP dentifrice showed additional microbiological activity |
| Goes et al. (2016) [11] | Randomized, double-blind, placebo-controlled pilot study | 30 fixed-orthodontic patients | 10–40 y | Both sexes | Placebo vs 0.12% CHX vs 1% Matricaria chamomilla mouthwash | CHX and MTC reduced visible plaque and gingival bleeding compared with placebo |
| Johal et al. (2023) [12] | Randomized, parallel, controlled, single-blind clinical trial | 84 orthodontic patients (40 manual; 44 powered) | 12–18 y | Not stated | Manual vs powered toothbrush | No significant long-term differences between groups |
| Koretsi et al. (2022) [13] | Two-period, balanced, randomized crossover clinical trial | 103 orthodontic patients | Children 10– 13 y; adults >18 y | Not stated | Brushing time: manual vs powered toothbrush | Age-related differences in brushing time and device use were reported |
| Al Shammari et al. (2022) [14] | Three-treatment, examiner-blinded crossover clinical trial | 24 fixed-orthodontic patients | Mean 19.58 y | Not stated | Manual toothbrush comparison (Pulsar, C-TB, O-TB) | C-TB and O-TB favored over Pulsar; no difference between C-TB and O-TB |
| Shilpa et al. (2019) [15] | Interventional, randomized, controlled, examiner-blind, parallel study | 111 fixed-orthodontic patients (37 per group) | 13–35 y | Not stated | Manual brushing vs powered brushing vs manual brushing + mouthwash | Powered brushing improved indices vs manual brushing; adjunctive CHX regimen showed the greatest overall improvement |
| Cenzato et al. (2024) [16] | Controlled experimental study | 60 participants (20 fixed; 20 aligners; 20 controls) | 12–65 y | 31F, 29M | Plaque analysis across appliance groups | Hygiene-related findings favored aligner therapy compared with conventional fixed appliances |
| Mei et al. (2023) [17] | Two-arm parallel randomized controlled trial | 60 fixed-orthodontic patients | 11–40 y | Not stated | Modified Bass technique vs orthodontic toothbrushing technique | Orthodontic brushing technique reduced PI more than modified Bass |
| Mummolo et al. (2022) [18] | Observational comparative study | 40 patients (20 metal wire retainer; 20 fiberglass retainer) | 28–33 y | Not stated | Retainer material comparison | Metal wire retainers showed better short-term plaque-control profile than fiberglass retainers |
| van Doornik et al. (2025) [19] | Randomized, double-blind, controlled clinical trial | 77 fixed-orthodontic patients | 12–16 y | Not stated | Plaque-identifying toothpaste vs control toothpaste | No significant additional plaque reduction with plaque-identifying toothpaste |
| Kim et al. (2024) [20] | Double-blind, randomized crossover clinical trial | 22 orthodontic patients | Not stated | Not stated | Ordinary toothbrush vs micro-current-emitting toothbrush | Microcurrent-emitting toothbrush reduced dental plaque index more effectively |
| Farook et al. (2023) [21] | Randomized clinical trial | 30 fixed-orthodontic patients | 18–25 y | Not stated | Manual brush head types (CA, FT, OT) | FT toothbrush removed more plaque after a single brushing than OT and CA |
| Terrana et al. (2019) [22] | Single-center randomized controlled clinical trial | 60 fixed-orthodontic patients | Mean 14.2 y | Not stated | Triple-headed toothbrush vs conventional manual toothbrush | Triple-headed toothbrush led to significantly lower plaque index |
| Erbe et al. (2018) [23] | Single-center, single-blind randomized controlled trial | 60 adolescents | 13–17 y | Not stated | Interactive power toothbrush vs manual toothbrush | Interactive power toothbrush was associated with superior plaque reduction and compliance |
| AlMoharib et al. (2024) [24] | Randomized clinical trial | 30 fixed-orthodontic adult patients (15 per group) | Adults >18 y | Not stated | Water jet flossing vs interdental flossing | Both approaches reduced plaque accumulation |
Note: BRP = Brazilian red propolis; CHX = chlorhexidine; C-TB/O-TB/CA/FT/OT = brush types as reported in the original studies; GBI = Gingival Bleeding Index; MTC = Matricaria chamomilla; PI = Plaque Index; VPI = Visible Plaque Index.
3.1 Manual versus powered toothbrushing
Johal et al. (2023) conducted a single-center, parallel-design randomized clinical trial in 84 adolescent orthodontic patients and reported no significant long-term difference between manual and powered toothbrushing [12]. Koretsi et al. (2022), in a randomized crossover trial, showed that brushing time varied by age group and device type, highlighting the behavioral component of plaque-control performance [13]. Erbe et al. (2018) reported greater plaque reduction and better compliance with an interactive power toothbrush than with a manual toothbrush among adolescents [23]. Kim et al. (2024) found a greater plaque index reduction with a microcurrent-emitting toothbrush than with an ordinary toothbrush in a randomized crossover study [20]. Al Shammari et al. (2022) further indicated that even among manual toothbrushes, brush design may affect plaque-removal efficacy in fixed orthodontic patients [14]. Overall, the evidence does not support a universal device recommendation; rather, powered or specialized brushes may be useful when adherence, dexterity, or plaque persistence represent clinical concerns [12–15,20,23].
3.2 Chemical adjuncts and toothpaste
Chemical adjuncts and dentifrices were evaluated in several short-term trials. Lotif et al. (2022) and Furtado Junior et al. (2020) reported clinical and/or microbiological benefits of Brazilian red propolis-containing dentifrices in orthodontic patients. However, the magnitude and clinical durability of these effects require cautious interpretation [9–10]. Goes et al. (2016) compared placebo, 0.12% chlorhexidine, and 1% Matricaria chamomilla mouthwash in patients with fixed orthodontic appliances and reported reductions in visible plaque and gingival bleeding in the active mouthwash groups [11]. Shilpa et al. (2019) found that a manual toothbrush plus chlorhexidine mouthwash regimen produced the greatest improvement in PI, GI, and MPBI among the tested approaches [15,39]. Conversely, van Doornik et al. (2025) reported that plaque-identifying toothpaste did not significantly reduce plaque compared with control toothpaste in adolescents with fixed appliances [19]. These findings indicate that chemical or dentifrice adjuncts may be useful in selected cases but should be integrated with mechanical plaque removal and appropriate clinical indication [8–11,15,19].
3.3 Brush design, technique, and interdental aids
Mei et al. (2023) showed that an orthodontic toothbrushing technique reduced plaque index more than the modified Bass technique in patients wearing fixed appliances [17,35]. Terrana et al. (2019) reported lower plaque index values with a triple-headed toothbrush compared with a conventional manual toothbrush in adolescents with fixed appliances [22]. Farook et al. (2023) found that the brush-head configuration influenced immediate plaque removal after a single brushing in fixed orthodontic patients [21]. Regarding interdental aids, AlMoharib et al. (2024) reported that both water jet flossing and interdental flossing reduced plaque accumulation in adult fixed-orthodontic patients [24]. Taken together, these findings support instruction specific to orthodontic anatomy, interdental access, and patient preference, rather than generic brushing advice alone [17,21–22,24,30].
3.4 Appliance type and retention phase
Cenzato et al. (2024) compared plaque and microbiological findings across fixed appliances, clear aligners, and controls and reported more favorable hygiene-related findings in the aligner group than in conventional fixed-appliance patients [16]. During the retention phase, Mummolo et al. (2022) reported short-term differences in plaque index and microbial colonization between metal and fiberglass retainers, with more favorable plaque-control findings for metal wire retainers [18]. These data indicate that appliance type and treatment phase should be considered when planning hygiene instructions and monitoring intervals [16,18].
Two descriptive figures are provided to support interpretation. Figure 2 summarizes the main intervention domains represented among the included studies, while Figure 3 presents a practical decision framework for tailoring plaque-control strategies. These figures are descriptive and should not be interpreted as pooled quantitative estimates.
The figure provides a descriptive, non-pooled summary of the main intervention domains. Categories are not mutually exclusive because some studies evaluated more than one plaque-control component.
The framework emphasizes appliance type, mechanical strategy, adjunctive therapy only when indicated, and longitudinal monitoring of plaque and gingival indices.
4. Discussion
This narrative review indicates that a single device or product does not determine plaque during single orthodontic treatment, but rather the interaction among appliance type, patient behavior, mechanical access, and adjunctive measures. Evidence comparing manual and powered toothbrushing remains mixed. Some trials reported advantages for interactive powered or microcurrent-emitting devices, while others found no significant difference between manual and powered brushing when instruction and adherence were adequate [12–13,20,2–3,36]. This heterogeneity is clinically important: it suggests that powered toothbrushes may be useful for selected patients, particularly those with persistent plaque accumulation or limited dexterity, but they should not replace individualized instruction and reinforcement. Brush design and technique also appear relevant. Orthodontic-specific brushing techniques, triple-headed toothbrushes, and selected brush-head designs improved plaque outcomes in some controlled studies. At the same time, interdental aids offered practical options for managing difficult-to-access areas around fixed appliances [14,17,21–22,24]. Chemical adjuncts and dentifrices may provide additional short-term benefit, especially in patients with gingival inflammation or poor plaque control despite instruction. However, chlorhexidine and other active products should be used with attention to indication, duration, adverse effects, and patient-specific risk, rather than as routine long-term substitutes for mechanical plaque removal [8–11,15,19,31]. Appliance type remains a further determinant of hygiene outcomes. Clear aligners may facilitate access to tooth surfaces because they are removable, whereas fixed appliances require more structured plaque-control support. Retention-phase design also warrants attention, as retainers may create plaque-retentive areas after active treatment has ended [16,18,29,32,40].
4.1 Appliance-specific strategies
| Appliance Type | Primary Recommendation |
|---|---|
| Clear aligners | Reinforce routine toothbrushing and cleaning of the internal aligner surface; monitor hygiene because removability does not eliminate plaque risk. |
| Fixed brackets | Provide orthodontic-specific brushing instruction, interdental aids, and individualized consideration of powered or specialized brushes when plaque persists. |
| Retention phase | Assess retainer design and plaque retention; provide specific instructions for cleaning around bonded retainers and monitor gingival response. |
4.2 Clinical implications
From a clinical perspective, the evidence supports repeated oral-hygiene instruction, reinforcement over time, and periodic monitoring of plaque and gingival indices during orthodontic therapy. Manual toothbrushing can be effective when technique and adherence are adequate. Still, powered toothbrushes, orthodontic-specific brush designs, and interdental aids may be advantageous in patients with persistent plaque, limited dexterity, or low adherence [12,14,17,20–24,34]. Chemical adjuncts such as chlorhexidine-containing mouthrinses or active dentifrices may be considered in selected patients and for appropriate time frames, especially when gingival inflammation persists despite mechanical plaque control [8–11,15,19,27–28].
4.3 Limitations
The included studies were heterogeneous in design, population characteristics, appliance type, interventions, follow-up duration, and outcome reporting, which limits direct comparability. Several trials had small sample sizes or short observation periods, and demographic information was not always complete. Because this is a narrative review, no pooled quantitative estimate was calculated, and no formal meta-analysis was performed. In addition, the evidence base remains uneven across intervention categories: some domains are supported by randomized trials, whereas appliance- and retention-related conclusions rely on fewer comparative studies. Future research should use standardized plaque and gingival indices, consistent follow-up intervals, transparent adherence measures, and longer observation periods to support more precise recommendations across appliance types and age groups.
5. Conclusion
Orthodontic appliances can increase plaque retention and may negatively affect gingival health when oral hygiene is inadequate. Current clinical evidence suggests that several strategies can support plaque control, including powered or specialized toothbrushes, orthodontic-specific brushing techniques, interdental aids, selected chemical adjuncts, and appliance-specific hygiene protocols. However, the evidence is heterogeneous and does not justify a universal “best device” recommendation. The most defensible clinical approach is individualized: clinicians should assess appliance type, baseline plaque control, gingival response, age, dexterity, motivation, and adherence, and should reinforce hygiene instructions throughout active treatment and retention.
Abbreviations
- Aa
- Aggregatibacter actinomycetemcomitans
- BRP
- Brazilian red propolis
- CA
- Brush head type “CA” (as reported in Farook et al.)
- CHX
- Chlorhexidine
- C-TB
- Manual toothbrush type “C-TB” (as reported in Al Shammari et al.)
- FT
- Brush head type “FT” (as reported in Farook et al.)
- GBI
- Gingival Bleeding Index
- GI
- Gingival Index
- MPBI
- Modified Papillary Bleeding Index
- MTC
- Matricaria chamomilla
- O-R
- Oscillating-rotating (powered toothbrush)
- O-TB
- Manual toothbrush type “O-TB” (as reported in Al Shammari et al.)
- OT
- Brush head type “OT” (as reported in Farook et al.)
- PI
- Plaque Index
- S. mutans
- Streptococcus mutans
- S. sobrinus
- Streptococcus sobrinus
- VPI
- Visible. Plaque Index
Funding:
This study was partially funded by the Italian Ministry of Health – Current Research IRCCS
Institutional Review Board Statement:
Not applicable. This article is a narrative review and did not involve new human-subject research.
Informed Consent Statement:
Not applicable. This article is a narrative review and did not involve new recruitment or intervention on human participants.
Data Availability Statement:
No new datasets were generated or analyzed. Data discussed in this article are available in the cited publications.
Conflicts of Interest:
The authors declare no conflicts of interest.
References
- 1. Cirulli N, Inchingolo AD, Patano A, Ceci S, Marinelli G, Malcangi G, Coloccia G, Montenegro V, Di Pede C, Ciocia AM, Barile G, Mancini A, Palmieri G, Azzollini D, Rapone B, Nucci L, Bordea IR, Scarano A, Lorusso F, Tartaglia GM, Maspero C, Nuzzolese M, Cardarelli F, Di Venere D, Inchingolo AM, Dipalma G, Inchingolo F. Innovative Application of Diathermy in Orthodontics: A Case Report. Int J Environ Res Public Health. 2022 Jun 17;19(12):7448. doi:10.3390/ijerph19127448. PMID: 35742704; PMCID: PMC9224328
- 2. Bollen AM, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects of orthodontic therapy on periodontal health: a systematic review of controlled evidence. J Am Dent Assoc. 2008;139:413–422. doi:10.14219/jada.archive.2008.0184. https://doi.org/10.14219/jada.archive.2008.0184
- 3. Malcangi G, Inchingolo AM, Casamassima L, Trilli I, Ferrante L, Inchingolo F, Palermo A, Inchingolo AD, Dipalma G. Effectiveness of Herbal Medicines with Anti-Inflammatory, Antimicrobial, and Antioxidant Properties in Improving Oral Health and Treating Gingivitis and Periodontitis: A Systematic Review. Nutrients. 2025 Feb 21;17(5):762. doi:10.3390/nu17050762. PMID: 40077632; PMCID: PMC11901544
- 4. Campobasso A, Lo Muzio E, Battista G, Ciavarella D, Crincoli V, Lo Muzio L. Taxonomic analysis of oral microbiome during orthodontic treatment. Int J Dent. 2021;2021:8275181. doi:10.1155/2021/8275181. https://doi.org/10.1155/2021/8275181
- 5. Scarano A, Inchingolo F, Scogna S, Leo L, Greco Lucchina A, Mavriqi L. Peri-implant disease caused by residual cement around implant- supported restorations: a clinical report. J Biol Regul Homeost Agents. 2021 Mar–Apr;35(2 Suppl. 1):211–216. doi:10.23812/21-2supp1-22. PMID: 34281319.
- 6. Loe H. The Gingival Index, the Plaque Index and the Retention Index systems. J Periodontol. 1967;38:610–616. doi:10.1902/jop.1967.38.6.610. https://doi.org/10.1902/jop.1967.38.6.610
- 7. Fuzio D, Inchingolo AM, Ruggieri V, Fasano M, Federico M, Mandorino M, Dirienzo L, Scacco S, Rizzello A, Delvecchio M, Parise M, Rana R, Faccilongo N, Rapone B, Inchingolo F, Mancini A, Fatone MC, Gnoni A, Dipalma G, Dirienzo G. Inflammation as Prognostic Hallmark of Clinical Outcome in Patients with SARS-CoV-2 Infection. Life (Basel). 2023 Jan 23;13(2):322. doi:10.3390/life13020322. PMID: 36836679; PMCID: PMC9966655.
- 8. Pithon MM, Sant’Anna LIDA, Baião FCS, dos Santos RL, Coqueiro RDS, Maia LC. Assessment of the effectiveness of mouthwashes in reducing cariogenic biofilm in orthodontic patients: a systematic review. J Dent. 2015;43:297–308. doi:10.1016/j.jdent.2014.12.010. https://doi.org/10.1016/j.jdent.2014.12.010
- 9. Lotif MAL, Valadas LAR, Fechine FV, Fonseca SGC, Bandeira MAM, Dantas TCFB, et al. A double-blind randomized clinical trial of Brazilian red propolis dentifrice efficacy in orthodontic patients. J Oral Sci. 2022;64:28–32. doi:10.2334/josnusd.21-0270. https://doi.org/10.2334/josnusd.21-0270
- 10. Malcangi G, Marinelli G, Di Giulio Cesare M, Di Serio S, Longo M, Carbonara A, Inchingolo F, Inchingolo AD, Bordea IR, Palermo A, Inchingolo AM, Dipalma G. Orthodontic Extrusion in Daily Clinical Practice: Management of Fractured or Damaged Anterior Teeth. J Pers Med. 2025 Sep 1;15(9):408. doi:10.3390/jpm15090408. PMID: 41003111; PMCID: PMC12470968.
- 11. Goes P, Dutra CS, Lisboa MRP, Gondim DV, Leitão R, Brito GAC, Rego RO. Clinical efficacy of a 1% Matricaria chamomile L. mouthwash and 0.12% chlorhexidine for gingivitis control in patients undergoing orthodontic treatment with fixed appliances. J Oral Sci. 2016;58:569–574. doi:10.2334/josnusd.16-0280. https://doi.org/10.2334/josnusd.16-0280
- 12. Johal A, Shagmani M, Alfuraih O, Arad I. Long-term comparison of the efficacy of manual versus powered tooth brushing in adolescent orthodontic patients: a single-centre, parallel design randomized clinical trial. Eur J Orthod. 2023;45:808–817. doi:10.1093/ejo/cjad042. https://doi.org/10.1093/ejo/cjad042
- 13. Malcangi G, Inchingolo AM, Casamassima L, Trilli I, Ferrante L, Inchingolo F, Palermo A, Inchingolo AD, Dipalma G. Effectiveness of Herbal Medicines with Anti-Inflammatory, Antimicrobial, and Antioxidant Properties in Improving Oral Health and Treating Gingivitis and Periodontitis: A Systematic Review. Nutrients. 2025 Feb 21;17(5):762. doi:10.3390/nu17050762. PMID: 40077632; PMCID: PMC11901544.
- 14. Al Shammari A, Farook FF, Fallatah A, Aldosari S, Ababneh KT, Aleissa BM. A randomized clinical study of the plaque removal efficacy of a novel manual toothbrush with micro-pulse bristles on fixed orthodontic patients. Cureus. 2022;14:e28453. doi:10.7759/cureus.28453. https://doi.org/10.7759/cureus.28453
- 15. Shilpa M, Jain J, Shahid F, Gufran K, Sam G, Khan MS. Efficacy of three types of plaque control methods during fixed orthodontic treatment: a randomized controlled trial. J Pharm Bioallied Sci. 2019;11:S246–S251. doi:10.4103/JPBS.JPBS_1_19. https://doi.org/10.4103/JPBS.JPBS_1_19
- 16. Ballini A, Cantore S, Farronato D, Cirulli N, Inchingolo F, Papa F, Malcangi G, Inchingolo AD, Dipalma G, Sardaro N, Lippolis R, Santacroce L, Coscia MF, Pettini F, De Vito D, Scacco S. Periodontal disease and bone pathogenesis: the crosstalk between cytokines and porphyromonas gingivalis. J Biol Regul Homeost Agents. 2015 Apr–Jun;29(2):273–81. PMID: 26122214.
- 17. Mei L, Kang A, Jin C, Farella M. An orthodontic tooth brushing technique to enhance oral hygiene in patients wearing fixed orthodontic appliances: a randomized controlled trial. Int J Dent Hyg. 2023;21:634–640. doi:10.1111/idh.12686. https://doi.org/10.1111/idh.12686
- 18. Mummolo S, Quinzi V, Nota A, Marino C, Pittari L, Manenti RJ, Tecco S. Metal versus fiberglass post-orthodontic retainers short-term effects on plaque index and microbial colonization: an observational study. Life (Basel). 2022;12:331. doi:10.3390/life12030331. https://doi.org/10.3390/life12030331
- 19. Inchingolo AD, Dipalma G, Inchingolo AM, Malcangi G, Santacroce L, D’Oria MT, Isacco CG, Bordea IR, Candrea S, Scarano A, Morandi B, Del Fabbro M, Farronato M, Tartaglia GM, Balzanelli MG, Ballini A, Nucci L, Lorusso F, Taschieri S, Inchingolo F. The 15-Months Clinical Experience of SARS-CoV-2: A Literature Review of Therapies and Adjuvants. Antioxidants (Basel). 2021 May 31;10(6):881. doi:10.3390/antiox10060881. PMID: 34072708; PMCID: PMC8226610.
- 20. Kim JH, Yu JH, Mangal U, Liu J, Jung HJ, Cha JY. Evaluation of dental plaque reduction using microcurrent-emitting toothbrushes in orthodontic patients: a randomized, double-blind, crossover clinical trial. Sci Rep. 2024;14:12126. doi:10.1038/s41598-024-60753-9. https://doi.org/10.1038/s41598-024-60753-9
- 21. Farook FF, Alrumi A, Aldalaan K, Ababneh K, Alshammari A, Al-Khamees AA, Albalawi F. The efficacy of manual toothbrushes in patients with fixed orthodontic appliances: a randomized clinical trial. BMC Oral Health. 2023;23:315. doi:10.1186/s12903-023-03035-6. https://doi.org/10.1186/s12903-023-03035-6
- 22. Inchingolo AD, Malcangi G, Semjonova A, Inchingolo AM, Patano A, Coloccia G, Ceci S, Marinelli G, Di Pede C, Ciocia AM, Mancini A, Palmieri G, Barile G, Settanni V, De Leonardis N, Rapone B, Piras F, Viapiano F, Cardarelli F, Nucci L, Bordea IR, Scarano A, Lorusso F, Palermo A, Costa S, Tartaglia GM, Corriero A, Brienza N, Di Venere D, Inchingolo F, Dipalma G. Oralbiotica/Oralbiotics: The Impact of Oral Microbiota on Dental Health and Demineralization: A Systematic Review of the Literature. Children (Basel). 2022 Jul 8;9(7):1014. doi:10.3390/children9071014. PMID: 35883998; PMCID: PMC9323959.
- 23. Erbe C, Klees V, Ferrari-Peron P, Ccahuana-Vasquez RA, Timm H, Grender J, et al. A comparative assessment of plaque removal and toothbrushing compliance between a manual and an interactive power toothbrush among adolescents: a single-center, single-blind randomized controlled trial. BMC Oral Health. 2018;18:130. doi:10.1186/s12903-018-0588-1. https://doi.org/10.1186/s12903-018-0588-1
- 24. AlMoharib HS, Alqasem A, Almusfer G, Aldosari MA, Almadhoon HW. The effectiveness of water jet flossing and interdental flossing for oral hygiene in orthodontic patients with fixed appliances: a randomized clinical trial. BMC Oral Health. 2024;24:498. doi:10.1186/s12903-024-04166-0. https://doi.org/10.1186/s12903-024-04166-0
- 25. Contaldo M, Fusco A, Stiuso P, Lama S, Gravina AG, Itro A, Federico A, Itro A, Dipalma G, Inchingolo F, Serpico R, Donnarumma G. Oral Microbiota and Salivary Levels of Oral Pathogens in Gastro-Intestinal Diseases: Current Knowledge and Exploratory Study. Microorganisms. 2021 May 14;9(5):1064. doi:10.3390/microorganisms9051064. PMID: 34069179; PMCID: PMC8156550.
- 26. van der Weijden GA, Hioe KPK. A systematic review of the effectiveness of self-performed mechanical plaque removal in adults with gingivitis using a manual toothbrush. J Clin Periodontol. 2005;32 Suppl 6:214–228. doi:10.1111/j.1600-051X.2005.00795.x. https://doi.org/10.1111/j.1600-051X.2005.00795.x
- 27. Furtado Junior JHC, Valadas LAR, Fonseca SGC, Lobo PLD, Calixto LHM, Lima AGF, et al. Clinical and microbiological evaluation of Brazilian red propolis containing-dentifrice in orthodontic patients: a randomized clinical trial. Evid Based Complement Alternat Med. 2020;2020:8532701. doi:10.1155/2020/8532701. https://doi.org/10.1155/2020/8532701
- 28. Popovici C, Bordea IR, Inchingolo AD, Inchingolo F, Inchingolo AM, Dipalma G, Muntean AL. Dental Splints and Sport Performance: A Review of the Current Literature. Dent J (Basel). 2025 Apr 18;13(4):170. doi:10.3390/dj13040170. PMID: 40277500; PMCID: PMC12025889.
- 29. Montenegro V, Inchingolo AD, Malcangi G, Limongelli L, Marinelli G, Coloccia G, Laudadio C, Patano A, Inchingolo F, Bordea IR, Scarano A, Greco Lucchina A, Lorusso F, Inchingolo AM, Dipalma G, Di Venere D, Laforgia A. Compliance of children with removable functional appliance with microchip integrated during covid-19 pandemic: a systematic review. J Biol Regul Homeost Agents. 2021 Mar–Apr;35(2 Suppl. 1):365–377. doi:10.23812/21-2supp1-37. PMID: 34281334.
- 30. van Doornik SP, van Kammen L, Ren Y, Manton DJ, Kuijpers-Jagtman AM. Effect of a plaque-identifying toothpaste on plaque amount in 12-16-year-olds with fixed orthodontic appliances: a randomised, double-blind, controlled clinical trial. Orthod Craniofac Res. 2025;28:627–635. doi:10.1111/ocr.12904. https://doi.org/10.1111/ocr.12904
- 31. Santacroce L, Sardaro N, Topi S, Pettini F, Bottalico L, Cantore S, Cascella G, Del Prete R, Dipalma G, Inchingolo F. The pivotal role of oral microbiota in health and disease. J Biol Regul Homeost Agents. 2020 Mar–Apr;34(2):733–737. doi:10.23812/20-127-L-45. PMID: 32492992.
- 32. Inchingolo AD, Marinelli G, Fiore A, Balestriere L, Carone C, Inchingolo F, Corsalini M, Di Venere D, Palermo A, Inchingolo AM, Dipalma G. Diagnostic Support in Dentistry Through Artificial Intelligence: A Systematic Review. Bioengineering (Basel). 2025 Nov 13;12(11):1244. doi:10.3390/bioengineering12111244. PMID: 41301200; PMCID: PMC12649694.
- 33. Koretsi V, Klinke R, Herreiner P, Proff P, Kirschneck C. Duration of toothbrushing with fixed appliances: a randomized crossover clinical trial. Eur J Orthod. 2022;44:252–257. doi:10.1093/ejo/cjab075. https://doi.org/10.1093/ejo/cjab075
- 34. Signorini L, De Leonardis F, Santacroce L, Haxhirexha K, Topi S, Fumarola L, Dipalma G, Coscia MF, Inchingolo F. Probiotics may modulate the impact of aging on adults. J Biol Regul Homeost Agents. 2020 Jul-Aug;34(4):1601–1606. doi:10.23812/20-393-L. PMID: 32909421.
- 35. van Gastel J, Quirynen M, Teughels W, Coucke W, Carels C. Longitudinal changes in microbiology and clinical periodontal variables after placement of fixed orthodontic appliances. J Periodontol. 2008;79:2078–2086. doi:10.1902/jop.2008.080153. https://doi.org/10.1902/jop.2008.080153
- 36. Gil-Pozo A, Astudillo-Rubio D, Ferrando Cascales Á, Inchingolo F, Hirata R, Sauro S, Delgado-Gaete A. Effect of gastric acids on the mechanical properties of conventional and CAD/CAM resin composites - An in-vitro study. J Mech Behav Biomed Mater. 2024 Jul;155:106565. doi:10.1016/j.jmbbm.2024.106565. Epub 2024 May 3. PMID: 38718723.
- 37. Cenzato N, Occhipinti C, D’Amici E, Savadori P, Baldini B, Maspero C. Microbiological analysis of plaque and its composition in three patient groups under different orthodontic treatments. Dent J (Basel). 2024;12:168. doi:10.3390/dj12060168. https://doi.org/10.3390/dj12060168
- 38. Terrana A, Rinchuse D, Zullo T, Marrone M. Comparing the plaque-removal ability of a triple-headed toothbrush versus a conventional manual toothbrush in adolescents with fixed orthodontic appliances: a single-center, randomized controlled clinical trial. Int Orthod. 2019;17:719–725. doi:10.1016/j.ortho.2019.08.010. https://doi.org/10.1016/j.ortho.2019.08.010
- 39. Silness J, Loe H. Periodontal disease in pregnancy. II. Correlation between oral hygiene and periodontal condition. Acta Odontol Scand. 1964;22:121–135. doi:10.3109/00016356408993968. https://doi.org/10.3109/00016356408993968
- 40. Marsh PD. Dental plaque as a biofilm and a microbial community: implications for health and disease. BMC Oral Health. 2006;6 Suppl 1:S14. doi:10.1186/1472-6831-6-S1-S14. https://doi.org/10.1186/1472-6831-6-S1-S14