Periodontology and orthodontics - an interface

Question 1

The interface

Answer 1

 Periodontal treatment for patients undergoing
Orthodontic treatment
 Orthodontic treatment for patients undergoing
Periodontal treatment
 Orthodontic indications for Periodontal treatment
 Periodontal indications for Orthodontic treatment

Question 2

Children and adolescents gingival disease

Answer 2

 Periodontal problems are a concern during orthodontic
treatment of children and adolescents
 Tissue resistance however appears to be higher in younger
patients
 Most plaque related acute gingival disease resolves on
removal of fixed appliances

Question 3

Gingivitis and fixed appliances

Answer 3

In children and
adolescents even if
gingivitis develops
in response to
orthodontic
appliances it
almost never
extends to
periodontitis

Question 4

Prevalence of periodontal disease as a function of age

Answer 4

 The percentage of
patients with pockets
of 5mm or greater
increases with age in a
group of orthodontic
patients referred to a uni ortho clinic
 In contrast
mucogingival
problems peak and
then decrease with
age

Question 5

Minimal perio involvement

Answer 5

 Before treatment is offered ideally a
course of structured
dental hygiene
instruction is offered
 All orthodontic
patients must take
extra care to clean the teeth
 Hygiene aids are often needed
-plaque scores can reduce as a result of structured OHI

Question 6

Methods of plaque control during treatment: areas to clean

Answer 6

Patients wearing fixed appliances find that the most difficult areas to clean are:
1. The mesial and distal area of each tooth
between the brackets
2. The gingival margin below the bracket

Question 7

Plaque control during treatment: special aids

Answer 7

Adequate cleansing is possible with a standard
toothbrush
-research shows special grooved ortho breushes are of no advantages
Special aids can often be useful for some patients:
1. Interproximal brush
2. Standard interspace brush
3. Powered rotary brush
4. Superfloss/Floss threader

Question 8

Electric rotary toothbrush

Answer 8

Better hygiene
control has now
been confirmed
with electric
tooth brushes

Question 9

Can periodontally involved adult patients have ortho treatment?

Answer 9

There is no
contraindication to
treating adults who
have periodontal
disease as long as
the disease is
brought under
control before and
during orthodontic
treatment

Question 10

Orthodontic treatment for patients

undergoing Periodontal treatment

Answer 10

 Periodontitis affects upto 40% of the adult
population over the age of 40
 Increased number of adult patients seeking
orthodontic treatment
 Therefore number of patients with periodontal
problems attending orthodontic practices is
significantly increasing
 Combined periodontal & orthodontic treatment
can greatly enhance periodontal health and dentofacial aesthetics

Question 11

Most common ortho problems found in perio compromised pts include:

Answer 11

• Proclination of
maxillary anterior
teeth
• Irregular interdental
spacing
• Rotation of teeth
• Overeruption
• Migration/loss of
teeth
• Traumatic Occlusion

Question 12

The need to control inflammation

Answer 12

If disease is not brought under control a combination
of inflammation, orthodontic forces and occlusal
trauma produce a more rapid destruction than would
occur with inflammation alone
 Boyd et al. (1989) showed that adults were more
effective than adolescents in removing plaque,
especially late in the orthodontic treatment
 Tooth movement in adults with a reduced but
healthy periodontium did not result in
significant further loss of attachment
 Adults with teeth that did not have healthy
periodontal tissues may experience breakdown
and tooth loss due to abscesses during
orthodontic treatment
 Artun and Urbye (1988) studied 24 patients
with advanced marginal bone loss and tooth
migration treated on average over 7 months
 They showed that the majority of sites
showed little or no additional loss of
supporting bone
 Nelson and Artun (1997) showed in a multi centre
study of 400 patients that a mean bone loss of 0.54mm
(SD 0.62) occurred
 2.5% of patients had a bone loss of 2mm or more

Question 13

How to identify active disease

Answer 13

Persistent bleeding
on probing is the
best indicator of
active and
progressive disease

Question 14

Groups at risk of perio

Answer 14

1. Those with minimal disease and no progression
   despite gingival inflammation (10%)
2. Those with moderate progression (80%)
3. Those with rapid progression (10%)

Question 15

Moderate periodontal involvement disease control

Answer 15

 All pre-existing
periodontal disease
must be brought
under control
 A period of
observation following
treatment will allow
complete healing and
ensure that there is in
fact adequate control
-removal of supra and sub gingival calculus
-RSD with and without surgical flaps
-osseus surgery and repositioned flaps can be performed before or after ortho depending upon condition

Question 16

Moderate perio involvement maintenance therapy

Answer 16

 Increased
frequency of
cleaning and
scaling depending
upon the severity
of the disease
 Therapy at 2-4
months is usual
throughout
treatment

Question 17

Reducing micro-organisms

Answer 17

 Molar bonding may
be advantageous in
periodontal cases as
bands can make
marginal cleansing
difficult
 Elastomeric rings
have higher levels of
micro-organisms and
wire ligatures or self
ligating brackets may
be preferred

Question 18

Periodontal surgery

Answer 18

E.g. perio drifting treated with fixed appliance surgery

Question 19

Perio treatment for ortho patients

Answer 19

OHI

Surgery (crown lengthening)

Question 20

Orthodontic indications for perio treatment: mimimal perio involvement (the attached gingiva)

Answer 20

Attached gingiva can be compromised by forward movement of lower labial segment

Question 21

LocalIsed gingival recession

Answer 21

 Preservation of the attached gingiva is essential

 Enthusiastic arch expansion can lead to recession

Question 22

Labial movement of lower incisors put the supporting tissues at risk

Answer 22

 Generally gingival recession follows an alveolar dehiscence
if the overlying tissues are stressed
 Recession can proceed rapidly if there is little attached
gingiva

Question 23

Non-passive retainer

Answer 23

Can act as fulcrum

-twists teeth

Question 24

Periodontal indication for orthodontic treatment

Answer 24

Class 2 div 1 - palatal trauma
Class 2 div 2 - lower labial trauma
Lower incisor crowding? Perio or ortho