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6 February 2025

Protocols and Technologies Used by Italian Dental Professionals to Maintain Good Oral Health in Orthodontic Patients Before, During and After Treatment: A Survey Study

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1
Department of Surgical, Medical, Dental and Morphological Sciences, University of Modena and Reggio Emilia, 41124 Modena, Italy
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Advanced Technologies in Oral Hygiene Sciences Academy, 70018 Rutigliano, Italy
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Department of Oral and Maxillofacial Sciences, “Sapienza” University of Rome, 00161 Rome, Italy
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Department of Biomedical Sciences, University of Sassari, 07100 Sassari, Italy
Oral2025, 5(1), 9;https://doi.org/10.3390/oral5010009
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Abstract

Background: Orthodontic appliances increase biofilm accumulation by expanding plaque retention sites. Enamel demineralization and periodontal inflammation are considered to be the most prevalent consequences of biofilm formation in orthodontic patients, with reported prevalence rates of up to 50%. To date, there are different procedures and indications that have been used for the treatment of these conditions. Therefore, professionals may use different technologies and protocols to control bacterial biofilm. The aim of this study was to investigate the protocols and technologies used by Italian dental professionals to maintain good oral health in orthodontic patients before, during and after treatment. Methods: A total of 155 dental professionals, dentists, dental hygienist students and dental hygienists, attending the Italian Academy of Advanced Technologies in Oral Hygiene Sciences (A.T.A.S.I.O.) congress, completed a questionnaire to identify prevention technologies and protocols before, during and after orthodontic treatment. Results: The results show equivalent responses between dentists and dental hygienists, with most dental hygienists more likely to personalize treatment. Remineralization technologies and protocols are selected based on patient characteristics. During professional oral hygiene sessions, the most commonly used technologies before, during and after therapy are ultrasonic scaler and airflow with powders. Mouthwashes and toothpastes are customized and shared with the patient, with remineralizing technologies predominant in toothpastes. After treatment, aesthetics is evaluated and the whitening protocol is selected based on the patient’s characteristics. Conclusions: There is not a specific prevention program associated with each orthodontic therapy in the literature, so it is necessary to tailor the treatment to best manage the risks of orthodontic therapy and maintain healthy tissues.

1. Introduction

Dental appearance is an important feature in determining the attractiveness of a face and thus plays a key role in human social interactions. Aesthetic standards are subjective and influenced by many factors, such as fashion, cultural traditions, personality, self-esteem, peers or, even, ideologies [1].
With the growing need for aesthetic procedures, orthodontic treatments have become increasingly popular in recent years [2]. Orthodontic treatment can provide more global benefits in terms of improved psychological and social well-being [3]. A key aspect of psychological well-being is self-esteem, which needs to be addressed with appropriate treatment [3].
The need for improved aesthetics has increased in recent years, even in older age groups [4]. For these reasons, fixed and aligner orthodontics have undergone significant technological development by improving comfort and facilitating oral hygiene methods [5].
Interceptive and functional orthodontics are more widespread in children and play an important role in preventing functional and aesthetic problems [6]. Adolescents have the greatest demand for aesthetics, and in recent years, this has included the adult population [7].
As with any medical therapy, orthodontic treatment exposes the patient to certain risks [8]. Ethically, the clinician must understand how these risks relate to each patient to ensure that they benefit from treatment [9,10,11]. The risks associated with orthodontic treatment can affect both hard tissues, with enamel demineralization, and soft tissues, with periodontal inflammation. Studies have shown that poor oral hygiene could prolong treatment duration and even compromise treatment outcomes [10,11,12]. The progression of gingivitis lesions to periodontal diseases could lead to irreversible loss of supporting tissue. These undesirable potential side effects could lead to unsatisfactory results or even to a premature discontinuation of orthodontic therapy [13,14,15].
Dental hygienists and dentists provide routine oral hygiene instructions to orthodontic patients. Therefore, patient motivation plays a crucial and decisive role in maintaining oral hygiene [14]. Factors such as proper oral hygiene, proper diet and regular dental check-ups are essential to prevent hard tooth tissue demineralization and periodontal diseases during orthodontic treatment [13,14,15]. Orthodontic appliances impair the self-cleaning of teeth by the tongue, cheeks and lip muscles during mastication and increase biofilm accumulation by expanding plaque retention sites around the components of fixed appliances attached to the teeth [10,11,16,17].
The use of orthodontic appliances, which are increasingly in demand due to aesthetic requirements and greater awareness of oral health, can lead to imbalances in the oral ecosystem [10,11]. Increased plaque accumulation and colonization by pathogenic bacteria, such as Streptococcus mutans and Lactobacilli, have been observed in patients with fixed orthodontic appliances due to the difficulty in maintaining good oral hygiene [10,14,18,19].
With aligners, plaque accumulation is more manageable to control because the device is removable, and hygiene procedures are easier [20]. Patients treated with aligners appear to develop less enamel demineralisation than patients treated with conventional orthodontic appliances [21].
It also appears that patients treated with aligners have better periodontal health than those treated with multibrackets, although the role of the pre-existing malocclusion is unclear [22].
Depending on the patient’s age, characteristics and type of malocclusion, different orthodontic therapies may be chosen. For these reasons, preventive dentists must evaluate these aspects to plan appropriate oral health maintenance therapies and good oral hygiene [23].
Oral hygiene is one of the major concerns of orthodontic patients [22,24]. Biofilm accumulation is better controlled in patients who habitually brush their teeth at least twice a daily, use interdental brushes, floss and attend frequent office visits [24,25]. The Plaque Index (PI) score and gingival bleeding is significantly lower in patients who control oral hygiene during orthodontic treatment. Patients should be continually educated on the benefits of oral hygiene to maintain gingival health and reduce biofilm adhesion to orthodontic appliances [26,27,28,29,30].
To avoid oral health risks during orthodontic therapy, it is necessary to periodically check the condition of hard and soft tissues to ensure that the goal of therapy is being achieved [31,32,33].
Given the importance of maintaining oral health before, during and after orthodontic treatment, it is important to investigate the preventive technologies and protocols used by practitioners. In this way, it will be possible to draw up recommendations for health and aesthetics, considering both the enamel and the periodontium.
The aim of this study was to investigate the protocols and technologies used by Italian dental professionals to maintain good oral health in orthodontic patients before, during and after treatment.

2. Materials and Methods

2.1. Study Design and Sample

This was a cross-sectional online survey conducted during the National Congress of the Academy of Advanced Technologies in Oral Hygiene Sciences (A.T.A.S.I.O.) on 2–3 February 2024 (Rome, Italy). Considering the present study as a pilot study in the population of Italian dental health professionals, a convenience sampling method was used [34]. The questionnaire and methodology of this study were conducted in accordance with the ethical standards of the Helsinki Declaration of 1964 and its subsequent amendments. Participation in the study was voluntary and no participant identifiers were collected.

2.2. Survey Administration

A self-designed questionnaire written in Italian was created specifically for the study. An online questionnaire using Google Forms was used to collect the data. The questionnaire consisted of a series of questions about protocols and technologies used by dental professionals to maintain good oral health in orthodontic patients before, during and after treatment.
The questionnaire consisted of a total of twenty-eight questions, six related to patient management before orthodontic treatment, sixteen during treatment and six after treatment (Table 1).
Table 1. The proposed questionnaire with the answers.
The questionnaire was made available online (Google form) and the link was distributed among the congress participants via a QR code shown during the congress and not delivered personally.

2.3. Statistical Analysis

Data were analysed using IBM Statistical Package for Social Sciences (IBM SPSS) version 24.0 (IBM Corp., Armonk, NY, USA). The analysis included descriptive statistics and frequency distribution (relative and absolute frequencies). All participants were divided into three groups according to their background: dental hygienists, dental hygiene students and dentists. Statistical comparisons between groups for each answer about protocols and technologies used to maintain good oral health in orthodontic patients before, during and after treatment were performed using Pearson’s chi-square test. The significance level was set at p < 0.05 for all statistical analyses.

3. Results

The study population consisted of a total of 190 dental hygienists, dental hygiene students and dentists attending the congress. One hundred and fifty-five participants responded to all survey questions; the response rate was 81.58% (155/190 surveys). One hundred and forty respondents (90.3%) were dental hygienists, 10 (6.5%) were dental hygiene students and five (3.2%) were dentists.
The results of the first part of the questionnaire regarding the protocols and technologies used by dentists to maintain good oral health in orthodontic patients prior to treatment can be seen in Table 2. No significant differences were observed between the groups of dentists in any of the questions.
Table 2. Statistical analysis of protocols and technologies used by dental professionals to maintain good oral health in orthodontic patients before treatment.
Most respondents (83.2%) felt that the plaque index should be between 8% and 15%. Notably, 70 participants (45.2%) responded with 15%. Sixty respondents (38.7%) felt that PSR was always necessary and 54 (34.8%) felt that PSR and a complete periodontal evaluation were always necessary.
One hundred and forty respondents (88%) stated that they always consider the presence of demineralization, and most of the respondents (99, 62.4%) perform remineralizing treatments, especially fluoride therapies (29, 18.7%), amorphous calcium phosphate (15, 9.7%), nanohydroxyapatite (2, 1.3%) and a combination of remineralizing therapies (51, 32.1%). However, the most frequently selected option (57, 36.8%) was “depends on the individual case”. Regarding the use of toothbrushes, most of the respondents (95, 61.3%) agreed that the choice depends on the clinical characteristics and personality profile of the patient. Forty-eight respondents (31%) suggested a mechanical toothbrush. Most professionals recommended the use of interdental instruments at home. Of the respondents, 106 (68.4%) affirmed that the choice depends on the patient’s clinical characteristics and personality profile, and 68 respondents (43.9%) selected the “interproximal brush” option.

3.1. Protocols and Technologies Used by Dental Professionals During Treatment

The results of the second part of the questionnaire on protocols and technologies used by dental professionals to maintain good oral health in orthodontic patients during treatment are presented in Table 3. Significant differences were observed between the groups of dental professionals in questions 2.3, 2.6, 2.8, 2.9, 2.11, 2.12, 2.14, 2.15 and 2.16.
Table 3. Statistical analysis of protocols and technologies used by dental professionals to maintain good oral health in orthodontic patients during treatment.
Most of the respondents (71, 45.8%) considered a plaque index score of 15% to be the limit for continuing orthodontic treatment. Eighty-eight respondents (56.4%) felt it was necessary to update the periodontal evaluation, 48 (31%) felt it was necessary to perform a PSR and 40 (25.5%) advocated performing a complete periodontal evaluation in addition to a PSR. For 101 participants (65.2%), oral hygiene recalls depended on each patient’s risk index.
Regarding the technologies to be used in fixed orthodontics, “ultrasonic scaler” was the most selected answer (137, 88.3%), followed by “airflow” (129, 83.2%), “rotating brush and prophylaxis paste” (82, 52.9%) and “scaler” (84, 54.2%). When considering orthodontics with aligners or mobile orthodontic appliance instead, 144 respondents (91.3%) selected “ultrasonic scaler” and 126 (81.3%) selected “airflow”. Almost all respondents (145, 93.5%) monitor for hard tissue demineralization “at every follow-up visit”.
When demineralizations are present, most of the respondents perform outpatient remineralization treatments: 63 (40.6%) use several remineralizing agents, 31 (20%) use fluoride, 12 (7.7%) use amorphous calcium phosphate. Forty-seven (29.7%) respondents selected “depends on the individual case”. Regarding home remineralization therapies, the most selected options were “with several remineralizing agents” (55, 35.5%) and “depends on the individual case” (49, 31.6%).
The most recommended toothbrush for patients wearing fixed orthodontic appliances (50, 32.3%) was a mechanical toothbrush. However, more than half of the respondents (86, 55.5%) selected “depends on clinical characteristics and personality profile of the patient”. The interdental instrument recommended to patients wearing fixed orthodontic appliances was “interproximal brush” (92, 59.3%), followed by “superfloss thread” (34.8%). The most recommended toothpaste to patients wearing fixed orthodontic appliances was remineralizing toothpaste (49.7%). Remineralizing mouthwash was also the most common choice (25.2%).
The most commonly indicated toothbrush for patients wearing aligners or mobile orthodontic appliances was a mechanical toothbrush (41.3%), but the majority of respondents indicated that the choice depends on the patient’s clinical characteristics and personality profile (53.5%). According to 97 (62.5%) of the respondents, the choice of interdental instrument depends on the patient’s clinical characteristics and personality profile. In total, 79 respondents (50.9%) chose “interproximal brush”. The type of toothpaste recommended to patients wearing mobile orthodontic appliances/aligners was remineralizing toothpaste (36.1%), but the majority of respondents indicated that the choice depends on the patient’s clinical characteristics and personality profile (54.8%). The same applies to the choice of mouthwash: “remineralizing mouthwash” (21.3%) and “depends on the patient’s clinical situation” (54.8%).

3.2. Protocols and Technologies Adopted by Dental Professionals After Treatment

The results of the third part of the questionnaire regarding the protocols and technologies used by dentists to maintain good oral health in orthodontic patients after the treatment are presented in Table 4. Significant differences were observed between the groups of dental professionals in question 3.2.
Table 4. Statistical analysis of protocols and technologies used by dental professionals to maintain good oral health in orthodontic patients after treatment.
The professional who oversees the removal of adhesive/composite materials needed for orthodontic therapy may be a dentist or dental hygienist. For 59.4% of respondents who oversees this is the dental hygienist, while 16.1% say it is the dentist. For most professionals, the tools used for debonding were tungsten carbide burs (85.8%), composite polisher (69.7%) and the Arkansas stone bur (65.8%). After debonding, most professionals report that they perform a remineralizing treatment with various remineralizing agents (29%) and one that is fluoride based (20%).
After orthodontic treatment, most professionals (133; 85.8%) always perform an aesthetic evaluation of the enamel. A whitening treatment can be performed considering the clinical situation of the patient (36.8%) and after a remineralization treatment (for 24.5%). In case of demineralization, home remineralization treatment (89.8%) and outpatient remineralization treatment (75.6%) were planned for the patient.

4. Discussion

This study reports the results of a survey of 155 participants, members of the Academy of Advanced Technologies in Oral Hygiene Sciences, on the prevention strategies used by dentists and dental hygienists before, during and after orthodontic treatment.
A low plaque index is required prior to treatment. There is no clear recommendation in the literature regarding the exact value of the plaque index. However, scientific evidence suggests that a plaque index of less than 10–15% is considered acceptable for patients not undergoing orthodontic treatment [31,32].
It is also suggested that maintaining a low plaque index may facilitate the initiation of orthodontic therapy by minimising the risk of enamel demineralisation and gingival inflammation (Table 1, Q1.1) [33].
According to the data collected, a plaque index of 15 percent is considered the threshold by most professionals (Table 1, Q1.1). The importance of periodontal assessment prior to treatment is also recognised by most professionals (Table 1, Q1.2) [35,36]. Periodontal health can be assessed by periodontal screening and recording (PSR) or by performing a complete periodontal chart. It is well documented in the literature that periodontal health is essential for the initiation of orthodontic therapy [36].
The principles of minimally invasive dentistry emphasise the need for clinically effective measures to remineralise early enamel caries lesions. Enamel health is critical to orthodontic therapy and is commonly assessed for demineralisation prior to treatment (Table 1, Q1.3) [37].
Fluoride-mediated remineralisation is considered the cornerstone of current caries management philosophies; however, several new remineralisation strategies claiming to promote deeper lesion remineralisation have been introduced and are under development [38].
The most common practice among professionals is to perform in-office remineralisation therapies using different remineralising agents, taking into account the individual characteristics of each patient (Table 2). The type of toothbrush recommended to patients depends on their clinical condition and individual characteristics (Table 2, Q1.5). Current manual brushing techniques, such as the “Bass modified” technique, are based on outdated concepts of oral hygiene that focus on specific movements and timing to disrupt the oral biofilm on tooth surfaces, regardless of the instruments or techniques used.
When selecting the most appropriate toothbrush, the clinical characteristics of the patient, including gingival biotype, dental anatomy and the presence of diastemata, should be carefully evaluated, along with clinical observation, plaque testing and new technologies to detect early tooth surface pathology (Table 2) [23].
In this study, most professionals recommended the use of an electric toothbrush, which has been shown to have a statistically significant advantage over manual toothbrushes and appears to be effective in reducing the signs and symptoms of periodontal disease [39,40]. Responses from dentists and dental hygienists are consistent, with no significant percentage differences.
Oral hygiene is particularly important for orthodontic patients whose treatment is prolonged. These patients have increased plaque accumulation and gingivitis. The irregular surfaces of orthodontic appliances limit the physiological cleaning mechanisms of the oral muscles and saliva [41].
Therefore, professional oral hygiene is generally recommended during orthodontic treatment, based on the patient’s risk indices and tailored therapy (Table 3, Q2.3, PI0.003). Statistical analysis indicates that this recommendation is statistically significant, with comparable responses from both dentists and dental hygienists. In patients undergoing fixed orthodontic appliance therapy, professional oral hygiene has been shown to significantly improve periodontal health [42]. Evaluation of periodontal changes before, during and after fixed orthodontic therapy shows that gingival hyperplasia is the most common periodontal disease and that patients with orthodontic appliances tend to have a high plaque index. This is particularly evident in fixed orthodontics, highlighting the importance of educating and motivating patients to maintain optimal oral hygiene to prevent periodontal disease [43].
Ultrasonic and air polishing devices are the most commonly used technologies by dental professionals during orthodontic treatment. Ultrasonic instrumentation is effective in reducing plaque levels in fixed orthodontic therapy, but caution is advised due to its potential to reduce the shear bond strength of metallic orthodontic brackets. Scaler tip angulation does not affect bond strength reduction or bond failure mode [44].
Sodium bicarbonate air polishing powder has been shown to be safe for intact enamel surfaces but is unsuitable for root surfaces or denuded dentin, particularly in cases where there is significant loss of hard tissue [21,43,45,46]. This has been confirmed by several studies aimed at quantifying the loss of root substance caused by air polishing, where defect depths of up to 856 µm have been reported [20,21,45,46,47,48,49].
Low-abrasion air polishing powders based on glycine and trehalose have been developed to optimise the efficacy and safety of air polishing on dentin or cement. These powders are effective in removing bacterial biofilm and are thought to have anti-inflammatory properties.
Glycine air polishing powder has been shown to be less abrasive than conventional sodium bicarbonate powder and to cause less trauma to gingival tissue. It has an anti-inflammatory activity and is suitable for both supragingival and subgingival applications, where it allows effective removal of plaque from root cement and dentin without significant damage [45,46,47,48,49,50].
In cases of demineralisation, the lesions are generally assessed by the clinician at each visit and remineralisation is performed with different agents depending on the individual situation (Table 3, Q2.7). Fluoride and amorphous calcium phosphate are the most commonly used agents for both outpatient and home treatment. Fluoride boosters such as calcium phosphates, polyphosphates and natural products can play an important role in enamel remineralisation [51].
Biomimetic hydroxyapatite toothpastes have been shown to be effective in preventing caries in the primary dentition and in preventing fluorosis [49]. Varnishes containing fluoride or casein phosphopeptide–amorphous calcium phosphate (CPP-ACP) promote remineralization [52].
Resin infiltration and fluoride varnishes are clinically feasible and effective for the treatment of anterior white spot lesions. Resin infiltration is now considered a valid alternative to fluoride treatment [53,54].
With regard to fixed orthodontic appliances, professionals indicated that the choice of toothbrush depends on the characteristics of the patient (Table 3, Q2.9). There is a notable difference in responses between dental hygienists and dentists. While most dentists recommend either powered or manual toothbrushes, dental hygienists typically evaluate patient characteristics and generally prefer the powered toothbrush, in line with the scientific literature [5,55].
Toothpaste recommendations are based on remineralising agents (Table 3, Q2.11) and mouthwashes are prescribed based on the clinical situation and personal characteristics of the patient (Table 3, Q2.12). The interdental brush is the most recommended interdental instrument (Table 3, Q2.10), with the choice again influenced by individual patient characteristics.
Hydroxyapatite is a promising biomimetic oral care agent, and further research is needed to confirm its clinical effectiveness in preventing and arresting dental lesions. Research comparing its effectiveness with fluoride toothpaste shows promising results. Fluoride toothpastes remain effective and their use is strongly recommended [56,57,58].
For aligners or removable orthodontic appliances, the indications given by participants are similar to those for fixed appliances, with smaller differences between dentists and dental hygienists. In this case, both groups emphasise that the choice of toothbrush depends on the clinical characteristics of the patient. The choice of interdental instruments is also based on the patient’s clinical situation (Table 3, Q2.14).
Comparing these findings with the literature, patients undergoing orthodontic treatment show qualitative and quantitative changes in the oral microbiome compared to untreated individuals, largely due to increased retention of bacterial plaque [59].
Clear aligners are considered preferable for high-risk patients, such as those prone to inflammation, enamel lesions and caries, due to better control of oral hygiene levels [60].
Preventive strategies during orthodontic treatment primarily include the use of topical fluoride, dietary hygiene (reducing the consumption of sugary and acidic foods), and maintaining optimal oral hygiene through home and professional mechanical plaque removal [23,32]. Clear aligners and, to a lesser extent, self-ligating brackets are thought to facilitate better oral hygiene than traditional fixed appliances. However, no significant differences in oral hygiene levels were observed between clear aligners, self-ligating brackets and conventional elastomeric brackets [61,62].
Most dental hygienists and dentists reported that adhesive and composite removal during orthodontic treatment is usually performed by the dental hygienist (Table 4, Q3.1), although there is no clear consensus in the literature regarding the professional responsible for this procedure. Tungsten carbide burs, Arkansas burs and composite polishers are commonly used for debonding.
Adhesive debris can be removed using a variety of methods, including tungsten carbide burs and high-speed handpieces, burs and high-speed or low-speed contra-angle handpieces, tungsten carbide burs and Soflex discs with high-speed or low-speed handpieces, and air abrasion with aluminium oxide [63,64]. The use of rotary instruments is currently the method of choice for adhesive removal [65,66].
Enamel remineralisation therapies are selected on a clinical and case-by-case basis using a variety of remineralising agents. Fluoride is the most used agent (Table 4).
After orthodontic treatment, professionals routinely evaluate the aesthetic appearance of enamel (Table 4, Q3.4) and consider whitening options on a case-by-case basis (Table 4, Q3.5). Whitening during orthodontic treatment can be effective if tailored to the patient’s aesthetic needs [67], although it is generally recommended to wait 1 to 3 months after the removal of braces before starting whitening treatment [68].
Most professionals consider the individual characteristics of the patient when prescribing a mouthwash, with the choice depending on the clinical situation.
Most of the responses are consistent with the scientific literature. In accordance with the literature and the responses, remineralising treatments and bacterial biofilm control are procedures to be considered before, during and after orthodontic therapy, with technologies and protocols chosen according to the situation [69,70,71].
Consistent with the literature, the results show that professionals pay attention to the health of the hard and soft tissues of the oral cavity. Before, during and after orthodontic therapy, professionals use technologies and therapeutic protocols that are personalised and shared with patients, and tailored motivational approaches can serve as valuable tools to promote oral health behaviours in individuals [72]. This study was conducted during a congress focused on oral health technologies and prevention. This may indicate an interest in improvement. It will be necessary to increase the sample later and to extend the study to other locations in the future. Some questions had the limitation that negative answers were not allowed.
New studies are needed to investigate specific protocols for each type of orthodontic therapy and to assess risk indices for oral lesions, caries and periodontal disease.

5. Conclusions

The results of this study show equivalent responses between dentists, dental hygienists and dental hygiene students. Based on the data collected, it appears that dental hygienists tend to personalize their treatments more than dentists.
The conclusions of this study can be summarized in seven main points:
  • Remineralization technologies and protocols are selected according to patient characteristics.
  • Ultrasonic and air polishing devices are the most commonly used technologies by dental hygienists and dentists for professional oral hygiene sessions before, during and after orthodontic treatment.
  • Most professionals, in accordance with the literature, have indicated that certain types of power toothbrushes are more effective than manual toothbrushes in reducing plaque and gingivitis.
  • Mouthwashes and toothpastes are customized according to the patient’s clinical characteristics and shared with the patient, with remineralizing technologies predominant in toothpastes.
  • After the treatment, the aesthetics are evaluated, and the whitening protocol is chosen according to the patient’s characteristics.
  • In the case of demineralisation of the tooth enamel, it would be necessary to intervene promptly with remineralising agents at home, such as toothpastes or mousses, or with professional applications, such as gels and varnishes.
  • In the case of gingivitis, home oral hygiene procedures should be reviewed, chemical antibacterial agents such as mouthwashes should be considered and, if necessary, a professional oral hygiene session should be performed.

Author Contributions

Conceptualization, S.S. and G.M.N.; methodology, S.S. and M.C.; validation, G.G., A.A.D.S. and R.G.; formal analysis, A.A.D.S. and G.G.; investigation, S.S. and M.C.; data curation, R.G.; writing—original draft preparation, S.S. and M.C.; writing—review and editing, A.A.D.S.; supervision, S.S. and G.M.N.; funding acquisition, G.M.N. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and the protocol was approved by Department of Oral and Maxillo Facial Sciences Research (cod. 0000239, date 8 February 2022).

Data Availability Statement

The raw data supporting the conclusions of this article will be made available by the corresponding author on request.

Acknowledgments

Marco Sabatini, for correcting the English.

Conflicts of Interest

The authors declare no conflicts of interest.

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A Mixed-Methods Study of the Challenges of Nurses in a Sri Lankan National Hospital in the Provision of Clinical Oral Hygiene Care
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