international dental journal 7 2 ( 2 0 2 2 ) 8 0 5 − 8 1 0

Scientific Research Report

Bitter Taste Perception and Dental Biofilm

Cariogenicity in Orthodontics

Nithivoot Luengthamchat a, Sittichai Koontongkaew a,

Kusumawadee Utispan b*
a
Walailak University, International College of Dentistry, Bangkok, Thailand
b
Faculty of Dentistry, Thammasat University (Rangsit Campus), Pathum Thani, Thailand

A R T I C L E I N F O A B S T R A C T

Article history: Background: Bitter taste perception and sweetness preference have been associated with
Received 6 April 2022 dental caries. Propylthiouracil (PROP) has been used to determine the genetic sensitivity to
Received in revised form bitter taste in early childhood caries. However, the role of the bitter threshold in dental bio-
25 June 2022 film cariogenicity has not been reported. The purpose of this study was to investigate the
Accepted 1 July 2022 role of individual taste sensitivity using PROP in dental biofilm cariogenicity in orthodontic
Available online 10 August 2022 patients.
Methods: Forty orthodontic patients (12−42 years old) undergoing fixed appliance orthodon-
Key words: tic treatment participated in this cross-sectional study. Their demographic, oral hygiene
Taste perception practice, and dietary habits data were obtained using a questionnaire. The patients’ bitter
PROP taste threshold was measured using a PROP assay. The patients were subsequently classi-
Three-tone plaque disclosing agent fied as super-tasters (STs), medium-tasters (MTs), and non-tasters (NTs). Dental biofilm
Dental biofilm cariogenicity was determined using a 3-tone disclosing gel that becomes pink (new dental
Orthodontic patients biofilm), purple (mature dental biofilm), and light blue (cariogenic dental biofilm) based on
dental biofilm maturity.
Results: The NT, MT, and ST groups comprised 10%, 27.5%, and 62.5% of the patients,
respectively. Most of the STs (56%) and MTs (63.6%) were female, whereas no females were
NTs. The dental biofilm cariogenicity was significantly different between the PROP bitter-
ness groups (P < .05). The highest percentage of mature biofilm, followed by cariogenic and
new biofilm, was found in the MT and ST groups. However, the cariogenic biofilm percent-
age was significantly higher compared with mature biofilm (P < .05) in the NT group. A low
frequency (<1 time/d) of sugary and acidic food intake between meals was observed in the
ST, MT, and NT groups with no significant difference amongst the groups (P > .05).
Conclusions: Cariogenic dental biofilm was highly present in orthodontic patients with the
NT phenotype.
Ó 2022 The Authors. Published by Elsevier Inc. on behalf of FDI World Dental Federation.
This is an open access article under the CC BY-NC-ND license
([Link]

Introduction brackets’ base.1,2 Orthodontic appliances create an ecological

environment favourable to qualitative and quantitative
Dental caries is the most common deleterious effect related changes in dental biofilm microorganisms.3 Fixed appliances,
to fixed orthodontic treatment. This risk is attributed to the including brackets, springs, and arch wires, impede access to
presence of brackets, arch wires, ligatures, and other ortho- the tooth surface, making it difficult to remove dental biofilm
dontic appliances that complicate oral hygiene measures and by mechanical cleaning. The ecological plaque hypothesis
leads to increased dental biofilm accumulation at the proposed that any major changes in local environmental con-
ditions, for example, high sucrose consumption, will alter the
competitiveness of specific bacteria within the dental biofilm
* Corresponding author. Faculty of Dentistry, Thammasat Univer-
and result in pathogenic dental biofilm formation.4 Acid pro-
sity (Rangsit Campus), Pathum Thani, 12120, Thailand.
E-mail address: [Link]@[Link] duction, acid tolerance, and intracellular and extracellular
(K. Utispan). substances affect dental biofilm cariogenicity.5 The number
[Link]
0020-6539/Ó 2022 The Authors. Published by Elsevier Inc. on behalf of FDI World Dental Federation. This is an open access article under
the CC BY-NC-ND license ([Link]
806 luengthamchat et al.

of cariogenic bacteria, including Streptococcus mutans and lac- was to investigate the cariogenicity of dental biofilm and die-
tobacilli, increase in the dental biofilm on teeth with fixed tary habits amongst orthodontic patients with different
orthodontic appliances.6 genetic sensitivities to the bitter taste of PROP.
The composition and properties of dental biofilm reflect
the oral environment. The 3‑tone plaque disclosing gel (GC
Tri Plaque ID GelTM ) was developed to identify caries risk in Methods
individuals.7 This gel contains red pigment (red Bengal), blue
pigment (brilliant blue FCF), and sucrose. The structure of Study design and participants
new dental biofilm is sparse, and the blue pigment easily
washes off, giving the new dental biofilm a pink/red colour. This cross-sectional study received ethical approval from
The mature dental biofilm (>48 hours) structure is dense; the Institutional Review Board, Walailak University, Thai-
thus, the blue and red pigments are trapped, resulting in a land (Project ID: WUEC-20-224-01/2) on August 10, 2020.
blue/purple colour. When contacting the high acid-producing The principles of the Declaration of Helsinki were followed
mature dental biofilm, the sucrose in the disclosing gel is in this study.21 Patients in this study included Thai
metabolised by acidogenic bacteria in the dental biofilm, patients (≥12 years old) who were undergoing orthodontic
increasing its acidic content. When the dental biofilm pH treatment at the Advanced Oral Health Center, Walailak
drops to pH <4.5, the dental biofilm becomes light blue. The University. The exclusion criteria were having a systemic
light blue−stained dental biofilm has high levels of S mutans.8 disease or on a long term/recent/current regimen of medi-
Therefore, regarding cariogenic potential, the light blue den- cations affecting taste perception or salivary flow, antibi-
tal biofilm is the most virulent, followed by the blue/purple otic therapy within the previous 6 months, and severe
and pink dental biofilm. periodontal problems. Written informed consent was
Several studies have demonstrated the relationship of obtained from all participants on the first test day. The
high sucrose consumption and dental caries.9 Orthodontists participants were recruited using a purposive sampling
commonly advise patients to avoid sugary and acidic foods to method based on the inclusion and exclusion criteria,
prevent enamel demineralisation.10,11 However, few studies which resulted in 40 participants.
have investigated sugar intake amongst patients undergoing
orthodontic treatment. A previous study demonstrated the PROP disk preparation
relationship between white spot lesions (WSLs) and the fre-
quency of consuming sugary foods/carbonated soft drinks in PROP preparation and quantification were performed as
orthodontic patients.12 However, a cross-sectional study described.17 Briefly, 50 mg propylthiouracil (PTU) tablets were
found no association between wearing an orthodontic appli- purchased from T.O. Chemical manufacturer. No. 1 Whatman
ance and daily sugar intake.13 filters (3 cm diameter, Sigma-Aldrich) were cut in half and
There are multiple links amongst taste perception, taste saturated with a 50-mmol/L PROP solution. PROP was eluted
preferences, food preferences, and food choices and the from randomly selected saturated disks by incubating each
amount of food consumed. Genetic sensitivity to taste may disk in 20 mL methanol overnight at room temperature. The
be associated with the preference for or rejection of some amount of PROP in the impregnated filter paper disks was
foods.14 There are 3 phenotypic responses to the taste of 6-n- quantified using spectrophotometry. Pure PROP (6-n-pro-
propylthiouracil (PROP): those perceiving minimal bitterness pylthiouracil, Sigma-Aldrich) was dissolved in methanol and
(non-tasters, NTs); moderate bitterness (medium tasters, used as a standard. The PROP standard was prepared at 6 con-
MTs); or extreme bitterness (super-tasters, STs).15 These dif- centrations (0−0.01 mg/mL). The absorbance of PROP in the
ferences in perceived bitterness are due to differences in methanol solution was measured at a 275-nm wavelength.
peripheral nerve sensitivity partly attributable to differences A calibration curve was constructed and the extracted PROP
in the gene encoding for a specific bitter taste receptor concentration was determined. We ascertained that the
(TAS2R38 gene). TAS2R38 variants (rs713598, rs1726866, and mean amount of PROP per disk was 0.412 § 0.017 mg, and the
rs10246939) and bitter and sweet taste preference are signifi- percentage coefficient of variation across the disks (n = 3) was
cantly associated.16 Sweet preference has been linked to 4.2%.
bitter taste sensitivity to PROP.15,17 A meta-analysis demon-
strated that the NT group exhibited a significantly higher PROP sensitivity test
decayed, missing, and filled teeth score than the MT and ST
groups.18 The PROP sensitivity test was performed as described.22 The
Most orthodontic trials have used the Silness and Loe pla- method included a sodium chloride (NaCl) rating in the PROP
que index. However, some plaque indices are inappropriate screening procedure. NaCl was included because the taste
for orthodontic patients. Thus, there is a need to further intensity of NaCl does not vary based on PROP taster status.
assess the practicability of the advocated methods.19 Further- NTs give a lower intensity rating to PROP than to NaCl, whilst
more a review on the effect of sugar consumption on caries MTs rate the intensity of PROP and NaCl as equally intense.
highlighted the lack of consistency and precision of dietary STs give much higher intensity ratings to PROP than to NaCl.
assessment methods in dental studies.20 Therefore, the pres- Therefore, it is recommended to use NaCl rating as a refer-
ent study used the 3-tone disclosing agent and the PROP sen- ence standard for clarifying the classification of participants
sitivity test to investigate dental biofilm cariogenicity and in case of a borderline PROP rating.23 Briefly, the participants
bitter taste perception, respectively. The aim of this study placed the disks impregnated with 50 mmol/L PROP or
 prop test and orthodontic treatment 807

1.0 mol/L NaCl on the anterior two-thirds of their tongue for Statistical analysis
30 seconds. The sensation’s intensity was rated by marking
the Labeled Magnitude Scale (LMS). The participants who Data analysis was performed using the Statistical Package of
gave lower intensity ratings to the PROP solutions than to Social Sciences (SPSS) version 25 (IBM Corp.). The normal dis-
those of NaCl or who rated the PROP disk lower than 13 mm tribution of the data was assessed with the Shapiro−Wilk and
on the LMS were classified as NTs; those who gave higher rat- Kolmogorov−Smirnov tests.27 Descriptive statistics are pre-
ings to PROP solutions than to the NaCl solutions or who sented as mean § standard deviation (SD), median, range,
rated the PROP disk higher than 67 mm on the LMS were clas- and percentage.28 The unpaired Student t test and one-way
sified as STs; and those who gave similar ratings to the 2 stim- analysis of variance (ANOVA) with Bonferroni post hoc test
uli or who rated the PROP disk with intermediate ratings (13 were used for parametric data. Otherwise, the nonparametric
−67 mm) were classified as MTs. Facial expressions were tests, Mann−Whitney U test,29 and Kruskal−Wallis with
observed during the testing to support the verbal response Dunn−Bonferroni post hoc test were used.30 The categorical
and to identify any ambiguous or conflicting response.24 data were analysed by chi-square test and Fisher exact test.31
The significance level was set at P ≤ .05.

Questionnaire and diet analysis

Results
Self-reported questionnaires were used to obtain the demo-
graphic characteristics (age and sex), the fixed orthodontic The Shapiro−Wilk and Kolmogorov−Smirnov tests demon-
therapy duration, and toothbrushing frequency. Dietary strated that the data were not normally distributed. There-
analysis was performed as described.25 The patients were fore, nonparametric statistics were used in the analysis.
required to record all food and drink consumed for 5 days,
which comprised 3 weekdays and a weekend. The patients The study population
were educated and motivated to enter everything that they
consumed in the chart from morning until bedtime. The aver- The demographic variables, treatment duration, oral hygiene
age number of exposures to sugar and acid between meals practice, and diet habits are shown in the Table. The study
over the 5 days was calculated for each patient. comprised 40 patients, aged 12 to 42 years (median = 28
years). There were 4 (10%) NT patients, 11 (27.5%) MT patients,
and 25 (62.5%) ST patients. Most ST (14/25, 56%) and MT (7/11,
Dental biofilm cariogenicity assessment using the 3-tone 63.6%) patients were female; however, there were no females
plaque disclosing gel who were NTs.
The orthodontic treatment duration (median and range) in
The 3-tone disclosing gel (GC Tri Plaque ID GelTM ) was used as the ST, MT, and NT groups were 9 (2−16), 8 (2−14), and 7.5
described.26 The most mature dental biofilm was recorded for (6−14) months, respectively (P > .05). The brushing frequency
each tooth. Based on the colour changes on the tooth surfa- was significantly different between the taster (ST and MT)
ces, the plaque maturing staining (PMS) was obtained using and NT groups (P < .05). Most patients’ sugar and acid food
the formula: intake between meals was <1 time/d. There was no signifi-
% PMS = (number of teeth with each coloured plaque/total cant difference in sugary/acidic food consumption between
number of teeth examined) x 100 meals between the taster groups (P > .05).

Table – Descriptive analysis of the demographic, fixed orthodontic therapy duration, toothbrushing frequency, and between-
meal sugar/acid food intake data based on bitter taste perception.
Variable ST, n = 25 (62.5%) MT, n = 11 (27.5%) NT, n = 4 (10%) P value
Age (years)
Median (min−max) 28 (12 41) 28 (20−42) 23 (20−30) .45a
Sex
Male, n (%) 11 (44) 4 (36.40) 4 (100) .08a
Female, n (%) 14 (56) 7 (63.60) 0 (0)
Fixed orthodontic therapy duration (mo)
Median (min−max) 9 (2 16) 8 (2 14) 7.50 (6 14) .76a
Toothbrushing frequency, n (%)
<2 times/d 1 (4) 0 (0) 2 (50) .02b
≥2 times/d 24 (96) 11 (100) 2 (50)
Between-meal sugary foods (times/d)
Median (min−max) 0.7 (0 2.4) 0.8 (0 2.4) 0.1 (0 1.4) .39a
Between-meal acidic foods (times/d)
Median (min−max) 0 (0 0.8) 0 (0 0.2) 0 (0 0) .53a

a
Kruskal−Wallis test.
b
ST and MT groups were combined as the taster group. Fisher exact test was used instead of the chi-square test because of assumption violation (P = .02; taster
vs NT).MT, medium-taster; NT, non-taster; ST, super-taster.
808 luengthamchat et al.

Fig. 1 – Dental biofilm staining using the 3-tone plaque-disclosing gel. Representative dental biofilm colours in the (A) super-
taster, (B) medium-taster, and (C) non-taster groups are shown.

Dental biofilm cariogenicity (median = 28.57, min max = 0 74.43) and pink dental biofilm
(median = 0, min max = 0 45.83), was found in the ST group.
Figure 1 presents the figures for dental biofilm staining in the All pairwise comparisons of dental biofilm maturity in the ST
ST, MT, and NT groups. The medians of the percentage PMS group were significantly different (P < .05). In the MT group,
in the ST, MT, and NT groups are illustrated in Figure 2. The the highest percentage of purple dental biofilm
highest percentage (median = 64.29, min-max = 28.57 100) of (median = 57.41, min max = 12.5 75) was found, and 30.77%
purple dental biofilm, followed by light blue dental biofilm (min max = 12.5 87.5) and 0% (min max=0 66.67) light blue

Fig. 2 – Percentage plaque maturing staining by sweetness preference. Different superscript letters indicate significant differ-
ences (P < .05) in plaque maturity between each taster group (Kruskal−Wallis and Dunn−Bonferroni post hoc test).
 prop test and orthodontic treatment 809

and pink dental biofilm, respectively, were observed. A signifi- We found no significant difference in sugar intake
cant difference was observed between the pink and light blue amongst the NT, MT, and ST groups. Our findings did not
dental biofilm and pink and purple dental biofilm (P < .05). agree with a previous report.43 However, a systematic review
However, the highest percentage of light blue dental biofilm revealed that only a small proportion of available studies
(median = 66.36%, min max=41.67% 75%) was observed in reported significant associations between taste sensitivity
the NT group, whilst 33.64% (min max = 25 54.17) and 0% and dietary intake.44 Another possible explanation for the
(min max = 0 0) were found for the purple and pink dental lack of a significant association between sugar consumption
biofilm, respectively. A pairwise difference was found between and bitterness preference in our study is that taste preference
pink and light blue dental biofilm (P < .05). is not a unique determinant of the type of food consumed or
the establishment of eating habits.14 Additionally, the under-
lying impact of socioenvironmental factors on individuals’
Discussion food choices cannot be ignored.45 Furthermore, in this study,
the effects of bitterness sensitivity on dental biofilm maturity
Our patients ranged from 12 to 42 years-old, which was simi- might be outweighed by the impact of oral hygiene instruc-
lar to the range to previous studies on the association of the tion. The results of his study should be interpreted with cau-
PROP sensitivity test and dental caries.32-35 Most patients tion, because the level of acidogenic bacteria, particularly S
were recruited into the study after wearing fixed appliances mutans, in dental biofilm and/or saliva was not investigated
for 2 to 9 months. This duration is long enough to observe in this study. Moreover, our participants were orthodontic
changes related to dental caries development. Increased sali- patients; thus, whether these results may generalise to other
vary flow rates and components were found after 1 month of groups is unclear.
orthodontic treatment.36 Furthermore, clinical WSL forma-
tion around an orthodontic attachment can occur 4 weeks
after beginning treatment.37,38 Conclusions
In the last decade, research has focused on the rela-
tionship between genetic taste sensitivity, as detected by This study demonstrated a difference in dental biofilm cario-
PROP, and dental caries.18 However, few studies have genicity amongst orthodontic patients with different genetic
investigated the influence of taste perception and dental sensitivities to the bitter taste of PROP.
caries in orthodontic patients. Most of the orthodontic
patients participating in this study were STs (62.5%), fol- Conflict of interest
lowed by MTs (27.5%) and NTs (10%). The prevalence of
tasters in this study was relatively high. This prevalence None disclosed.
pattern was similar to a previous study33; however, it was
not in line with other studies.22,39
The prevalence of WSLs was significantly higher in adoles- Acknowledgements
cent orthodontic patients who were PROP NTs compared with
PROP tasters.39 This study suggested that PROP taste percep- We thank Christian Estacio, a native English speaker and Aca-
tion could be a potential risk factor for WSL formation during demic Counselor for International Affairs, Walailak Univer-
fixed orthodontic treatment. However, no study has focused sity, International College of Dentistry for his English editing.
on bitterness perception, sweetness preference, and dental
biofilm cariogenicity. In this study, similar dental biofilm
maturity distribution patterns were observed in the MT and Funding
ST groups. Matured dental biofilm was markedly observed in
both groups compared with new and cariogenic dental bio- This work was supported by Walailak University, Interna-
film. However, although this study had a small sample size, tional College of Dentistry (Grant Number: WUICD-B2020).
the highest percentage of cariogenic plaque was found in the
NT participants. Therefore, our findings provide additional R E F E R E N C E S
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