With more people presenting to dental practices with symptoms of periodontitis, clinical challenges have increased in almost all dental specialties including orthodontics. Dental Tribune ONLINE spoke with congress presenter Dr Frank Weiland from Austria about the effects of periodontal disease on orthodontic
treatment and vice versa.

Dental Tribune ONLINE: Periodontal disease and orthodontics have a complex interrelationship. What new insights have been obtained in the last three years?
Dr Frank Weiland: Each intervention causes damage, which is a known fact and also true for orthodontics. Clinicians have to reckon with some attachment loss and recession down to tenths of a millimetre with orthodontic treatment. The most significant danger comes from (additional) plaque-induced infection, that is why orthodontic devices should be designed in a way that they can be cleaned thoroughly by the patient (i.e. no bands, simple biomechanics and no elastic ligatures).

Computer-supported calculations have also revealed new knowledge about the changed biomechanical requirements and the use of the treatment device in relation to the amount of force and the moment-to-force ratio.

What is the likelihood nowadays that a patient with orthodontic problems also has periodontal disease?
Since an increasing number of adults ask for orthodontic treatment, we as orthodontists are automatically confronted with more patients suffering from symptoms of periodontal disease. It is not rare that its clinical effects, such as tooth migration, are the main reason for orthodontic corrections. Periodontal problems can be of a chronic nature, but, on the other hand, be rapidly progressive and lead to tooth loss at a relatively young age. The point here is that orthodontic tooth movement is based on sterile inflammation. If you add an additional bacteria-induced inflammation, this can result in significant attachment loss.

Orthodontic correction can also have a negative effect on periodontal status. When should clinicians desist from treatment?
As I mentioned before, the most important contra-indication is periodontal tissue that is not clinically free of inflammation. With support from the dentist, orthodontist and periodontist, patients should be able to maintain conditions that are free of inflammation.

Periodontitis can also break out during orthodontic treatment. What are the clinical symptoms that orthodontists should be aware of?
The common alarm signals include gum bleeding, gingival recession, loss of papillae and clinical signs of inflammation such as bleeding on probing.

What role does the age of the patient play?
Age is only a relative factor. It is actually more about the aggression of the periodontal disease and the extent of deterioration.

Orthodontists are recommended to consult a general dentist or periodontist prior to treatment. Is this common practice?
I am only able to speak here for my own practice. In many cases, patients who present for the first time already have the respective documentation from their general dentists and periodontists. Prior to treatment of adult patients, a basic periodontal evaluation (BPE) and, if needed, a pretreatment in our practice, or by the dentist and in critical situations by a periodontist is performed. Orthodontic treatment does not begin until these professionals have given the green light. Subsequently, regular control visits are an absolute necessity.

Is there any knowledge about whether and which treatment methods are able to halt the progression of periodontal disease?
A clear relation between tooth displacement and periodontal problems has been described. Significantly more pathogenic bacteria are found in crowded areas than in straight teeth. Of course, dental hygiene measures are also easier to perform in straight teeth than in a case of distinct crowding. It has been observed that former orthodontic patients had better oral health after correction than similar subjects whose teeth were not corrected, which is explained by routine checks and patient education.

Owing to attachment loss, tooth movements may occur that have a negative effect on future stability. An example of this is the protrusion of the upper incisors, which can cause an interposition of the lips with a leverage effect on the incisors. Clinical prospects for these teeth are significantly improved by moving them to a functional and aesthetically pleasing position. This is also valid for jiggling in the presence of periodontal inflammation, which could also lead to significant attachment loss.

Should the evaluation and monitoring of periodontal disease generally form part of orthodontic treatment?
No doubt. Regardless of the patient’s age, orthodontic treatment should never be performed if the patient’s oral health is insufficient. From my point of view, a check of the periodontal status, as recommended by the Austrian Society of Periodontology, as well as periodontal therapy of adult patients should be considered prior to orthodontic measures. Risk patients should be monitored at least every three months by the periodontist. Even after orthodontic treatment has been stopped, long-term success can only be achieved when the two Rs (Retention and Recall) are taken into account.

Thank you very much for this interview.