The Interplay Between Periodontal Health and Orthodontic Treatment: Optimising Patient Outcomes

However, even minor periodontal inflammation or plaque buildup can introduce challenges, affecting the structural and aesthetic goals of orthodontic therapy. Given these stakes, a multidisciplinary approach involving orthodontists, periodontists, and dental hygienists is essential to provide comprehensive care, address key risks, and support effective treatment outcomes.

The effect of periodontal health and disease on tooth movement

Healthy periodontal tissues are essential for effective tooth movement in orthodontics, providing a stable foundation that supports safe and efficient treatment. In patients with compromised periodontal health, however, inflammation can disrupt this process, slowing progress and increasing the risk of further complications.

A review paper by Antoun et al. (2017) highlights how reduced periodontal support can lead to complex orthodontic issues such as labial flaring, extrusion, and drifting, especially in maxillary incisors prone to over-eruption and pathological migration. These changes often require interdisciplinary treatment to achieve functional and aesthetic outcomes, with adjunct orthodontic treatments – like extrusion of unrestorable teeth – playing a role in optimising bone and soft-tissue architecture for dental implant placement.

Notably, periodontal disease does not necessarily contraindicate orthodontic treatment if inflammation is stabilised. However, bone loss and reduced soft-tissue structure can pose significant rehabilitation challenges.

In periodontally healthy patients, Jepsen et al. (2023) found that orthodontic treatment typically has no detrimental effects on periodontal tissues. Still, clinicians must recognise and manage common complications, including inflammatory gingival overgrowth and root resorption, which can escalate without proper care. Maintaining periodontal health and hygiene before and throughout treatment is crucial to avoid these issues.

Orthodontic treatment of patients with periodontal disease

Managing orthodontic treatment for patients with periodontal disease requires meticulous planning and control of inflammation. According to Jepsen et al. (2023), orthodontic movement of teeth with reduced, healthy periodontium does not lead to additional attachment loss. However, in cases where plaque-induced inflammation and intrabony defects are present, orthodontic forces can exacerbate connective tissue loss.

The European Federation of Periodontology’s S3 clinical practice guideline outlines specific recommendations for patients with stage IV periodontitis. For instance, orthodontic treatment may proceed in patients with stable periodontal conditions and no probing depths ≥6 mm or active bleeding on probing. Treatment in these cases has been shown to not significantly affect periodontal outcomes, gingival inflammation, or root resorption. Conversely, beginning orthodontic treatment on patients with undiagnosed periodontitis is regarded as a treatment error, preventable with thorough periodontal screening prior to treatment. The guideline also recommends that orthodontic treatment in successfully treated periodontitis patients only commence after reaching periodontal therapy endpoints, such as minimal probing pocket depth (Jepsen et al., 2023). In cases involving untreated periodontitis, orthodontic movement should be delayed until periodontal therapy is complete to avoid worsening periodontal conditions.

Orthodontic treatment as a risk for periodontal health: Impact on the oral microbiome

Orthodontic appliances introduce physical changes that disrupt the oral microbiome, making periodontal management more challenging. Peterson et al. (2024) explain that the oral microbiome, which stabilises by early childhood, can be disrupted by orthodontic interventions, potentially leading to dysbiosis and an increase in pathogenic bacteria. Orthodontic appliances provide new surfaces for bacterial attachment and biofilm formation, increasing risks of gingivitis and caries. 

Patients undergoing orthodontic treatment typically exhibit shifts in microbial composition, driven by increased biofilm retention around orthodontic hardware. Research indicates that proactive hygiene measures are critical to counteract these shifts, as proper hygiene regimens often prove more effective than factors like appliance type or material. Probiotics and prebiotics are gaining traction as strategies to support microbial balance and reduce pathogenicity. 

Advances in biomaterials also offer promising solutions. For example, 3D-printed appliances with antimicrobial properties or biofilm-resistant coatings can help reduce bacterial retention. Innovations that respond to microbial changes, such as materials that release antimicrobials in response to pH changes, are also under development and could support personalised, microbiome-friendly orthodontic care.

The need for a collaborative approach in treatment planning

A collaborative, team-based approach to orthodontic treatment is key to protecting periodontal health. Periodontists ensure that gum health is stable enough for orthodontic forces, while orthodontists plan tooth movement to minimise periodontal stress. Dental hygienists play a preventive role, educating and motivating patients and providing cleanings to maintain optimal oral hygiene throughout treatment.

Tailored treatment plans

Each patient’s periodontal and orthodontic needs are unique, necessitating individualised treatment plans informed by input from multiple specialists. Regular check-ups and clear communication among orthodontists, periodontists, and hygienists help ensure that treatment strategies remain aligned with the patient’s evolving periodontal health.

Post-orthodontic care and long-term maintenance

Even after orthodontic treatment, periodontal maintenance remains essential for long-term health and stability. Proper care of retainers, combined with regular monitoring by dental professionals, can help prevent relapse or the emergence of new periodontal issues. Long-term follow-up care by hygienists and periodontists is instrumental in detecting and managing any emerging periodontal conditions.

Achieving optimal orthodontic outcomes through periodontal health

The interplay between periodontal and orthodontic health is essential for achieving safe, functional, and aesthetic outcomes. By adopting a multidisciplinary approach, clinicians can ensure that patients achieve optimal results without compromising periodontal health. This balance requires the combined efforts of orthodontists, periodontists, and dental hygienists at every stage of care, from treatment planning to post-treatment maintenance.