Perio-ortho synergy: “Excellent periodontal health is mandatory for a predictable orthodontic outcome”

Dr Garmyn, you recently chaired Perio Master Clinic 2023, which focused on a combined periodontal and orthodontic treatment approach. Why do you think this area of cooperation has sometimes been overlooked, and why is it important for clinicians to focus on it?
Very often, periodontists have the ability to treat Stage IV (severe) periodontitis cases successfully and prevent further tooth loss, leaving patients with good oral heath, a conditio sine qua non for good general heath. However, achieving the final goal of restoring both good mastication and optimal aesthetics in patients who are scared by the severe disease requires—in too many cases—single- or multiple-tooth replacement and orthodontic treatment. Therefore, it is mandatory to have a good team approach from the onset of treatment planning so that every single team member—general dentist, orthodontist, periodontist or restorative dentist—shares the same aims for the treatment outcome. Of course, the individual patient needs to be at the centre of the team approach.

Often, dental specialists and general dentists are aware of possibilities and limitations in treatment, but still overlook the importance of a team approach. Perio Master Clinic 2023 was particularly interesting because it emphasised the need to always aim for the best team approach and team planning when treating periodontally compromised patients.

Dr Garmyn, how common is the emergence of periodontal problems in orthodontic patients, and what strategies can be further implemented to prevent them?
To answer the question as phrased, orthodontic patients are most often young adults or teenagers seeking better occlusion and aesthetics. In these young patients, periodontitis is rare and gingivitis is rather frequent. Periodontal complications can occur and, in many cases, can be prevented through easy interventions that are often performed by dental hygienists dealing with optimal plaque control.

Some orthodontic patients need periodontal or surgical intervention because they need treatment for tooth impaction, have dental agenesis (which is usually hereditary) or have a very thin biotype, having a lack of keratinised tissue surrounding the teeth and a high risk of gingival recession. These orthodontic patients are in the minority. I am not aware of the statistics, but what I see at my office is that only around 5%–10% of orthodontic cases require a periodontist, and periodontal complications can be prevented in 50% of cases by engaging a dental hygienist.

However, if we consider how many periodontal patients need orthodontic treatment, I would say that at least 50% of severe periodontitis patients (and patients with crowding showing gingival recession) would benefit from orthodontic treatment.

Prof. Monnet-Corti, as scientific chair of Perio Master Clinic 2023, what can you tell us about the existing literature concerning a perio-ortho synergy and research therein that focuses on preventive care?
For a long time—until last year—there were few scientific publications on a synergy between orthodontics and periodontics. That is not to say that the subject was not previously discussed in lectures given by leading clinical experts in both fields. The publication of the study by Karin Jepsen et al. in 2021 demonstrated the value of multicentre randomised clinical trials involving orthodontists and periodontists. This paper received an award from the American Academy of Periodontology because it was so innovative and important in terms of clinical relevance. The idea was born out of sometimes heated debates between clinicians about the best time to start orthodontic treatment after successful periodontal treatment and especially whether the dental movement produced could improve or deteriorate the periodontal regeneration.

Unfortunately, scientific research on preventive care for periodontal patients undergoing orthodontic treatment is not very abundant. The literature is mainly focused on the difference in clinical (and sometimes microbiological) periodontal parameters in all types of patients (periodontal or not, adolescents, or young or older adult). It seems that there is less gingival inflammation with aligners compared with fixed vestibular or lingual appliances. However, specific studies of adult periodontal patients are needed to prevent the risk of recurrence or periodontal complications. Similarly, no scientific evidence has yet been established on the best frequency of periodontal maintenance visits during orthodontic treatment in a periodontal patient. The calculation of periodontal risk does not seem to be sufficient, and according to the clinical experts, it would be more judicious to ensure a follow-up of these patients by a hygienist every six to eight weeks to intercept any recurrence early.

Because orthodontic treatment will reduce or even eliminate diastemas secondary to periodontitis, constant recalibration of interdental cleaning methods must be consciously undertaken. We also know that the use of powered toothbrushes will not damage orthodontic appliances or periodontal tissues but will help the patient to maintain optimal plaque control despite the discomfort caused by the appliances.

Why is a perio-ortho synergy important in the context of preventive oral care, and in which areas can it be incorporated?
Prof. Monnet-Corti: As Perio Master Clinic 2023 attendees learned, very advanced periodontitis, Stage III or IV, is characterised by loss of clinical attachment and, very often, pathological tooth migration, such as drifting, flaring and bite collapse.

Orthodontic treatment helps to realign the migrated teeth and to prepare the edentulous spaces to replace the teeth in the best conditions. This harmonious distribution of interdental and inter-arch relationships helps prevent periodontal disease and occlusal disorders and improves the quality of life of periodontal patients.

Dr Garmyn: In orthodontic treatment, patients visit a dentist with specialist expertise often at a young age. During orthodontic treatment, they are motivated and instructed on how to maintain good oral hygiene. If they remain motivated and understand the importance of a good aftercare and follow-up, periodontal problems can surely be prevented in the majority of these patients.

Excellent periodontal health is mandatory for a predictable orthodontic outcome. Good orthodontists are very much aware of this and screen patients for gingivitis or periodontitis before starting orthodontic treatment.

Prof. Monnet-Corti, your own research interests include periodontal plastic surgery and aesthetics, and periodontics’ relationship with orthodontics. Did Perio Master Clinic 2023 spark fresh curiosity for you in relation to these topics?
Yes! A particularly interesting topic is the occurrence of gingival recession long after orthodontic treatment has been completed and a retention wire has been bonded. It seems to me that it is appropriate to prevent this type of periodontal lesion from appearing. It is not related to dental movements during orthodontic treatment but to uncontrolled movement generated by the retention itself in the context of a probably fragile periodontal phenotype. A session at the event addressed this topic.

The popularity of clear aligner therapy has led to growth in orthodontic patient numbers. Dr Garmyn, as president of the Belgian Society of Periodontology, do you have any concerns about the growing use of clear aligners in relation to periodontal problems?
Indeed, clear aligners are becoming a popular treatment approach, often because patients experience aligners as a more aesthetic and faster treatment option compared with fixed appliances. However, if used properly, clear aligner therapy should not necessarily mean reduced chair time. This is the first pitfall. Lingual brackets also have limitations as an aesthetic alternative. As a removable appliance, aligners interfere less with the plaque control (oral hygiene) measures that patients are required to perform, whereas fixed brackets and wires require more plaque control measures and make maintaining good oral hygiene a bit more difficult.

“[Aligner] therapy is often mistaken to be a treatment that requires less chair time” – Dr Peter Garmyn

Aligners, often because of promotion by the industry, are also becoming more popular as a treatment approach performed by general dentists. In my personal opinion, it is not aligners, per se, that lead to the biggest pitfalls; rather, it is treatment planning, which is often trusted to clear aligner companies. To clarify, I am not saying that a general dentist should not perform orthodontic or periodontal treatment. I would be the first one to encourage this. However, having good knowledge of the treatment, accepting its limitations and having good treatment planning are essential. In many cases, aligners can be a valid treatment concept. Alternatives and a good diagnosis of the patient’s skeletal, dental and periodontal situation prior to the treatment should never be overlooked, as these are key to a good treatment outcome.

In terms of supervision of the treatment, aligner therapy is often mistaken to be a treatment that requires less chair time. However, monitoring the periodontal and dental parameters, plaque and gingivitis scores, and early caries detection and dealing with the new window of infectivity created in patients, whether treated with aligners or fixed appliances, should always be well taken care of.

I am aware of some patients being sent home with a set of ten to 12 aligners and not receiving any professional supervision during the course of treatment! For sure, this is not the way to perform orthodontic therapy. It would be easy to label aligner treatment an inferior therapy concept in these patients. However, it is not the aligner treatment as such that causes the complications; rather, it is the lack of good planning or supervision.

Prof. Monnet-Corti, multidisciplinary approaches to periodontal care have become a greater focus for clinicians in recent years. What has changed?
What has changed is that more practitioners are aware firstly that some rehabilitation of masticatory function in the periodontal patient is not possible without orthodontics and secondly that the periodontal patient can benefit from orthodontic treatment without risk, provided that the practitioners work with orthodontists who are aware of the risks. I would add that adult patients are now less reluctant to undergo such treatment. There are many benefits to better oral and general health.

In which areas could periodontists, orthodontists and general dentists further collaborate to improve preventive oral care?
Prof. Monnet-Corti: They could collaborate more to improve preventive oral care by more frequently proposing wisely combined treatments even for so-called minor dental displacements—which can prevent the appearance of major pathologies such as periodontitis, caries and occlusal dysfunction.

Dr Garmyn: In Belgium, there are long waiting lists for appointments at all dental clinics—particularly for specialists—and some clinics are not able to accept new patients. Good planning and communication can make life easier for each practitioner. All parties should be involved not only in achieving treatment goals by establishing an optimal treatment timeline for each practitioner but also in the follow-up, retention control and maintenance therapy. Of course, this also includes dental hygienists, who constitute a new group of dental professionals in Belgium. Via the Belgian Society of Periodontology, we lobbied for 40 years to have dental hygienists recognised as professional members of the dental team.

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