Inconclusive Evidence of the Effects of

Orthodontic Therapy on Periodontal Health

Mina H. Chung and Robbie W. Henwood
JADA 2009;140(5):575-576

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 R E S E A R C H CRITICAL SUMMARIES

Inconclusive evidence of the effects of

orthodontic therapy on periodontal health

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A critical summary of Bollen AM, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects
of orthodontic therapy on periodontal health: a systematic review of controlled evidence.
JADA 2008;139(4):413-422.

Mina H. Chung, DDS, MS; Robbie W. Henwood, DDS, PhD

Main results. There was incon-

Systematic review conclusion. The association between orthodontic therapy
clusive evidence to support any posi-
and improved periodontal health cannot be verified. However, limited evidence
tive association between orthodontic
suggests a slight worsening of periodontal health after orthodontic therapy. therapy and periodontal health.
Critical summary assessment. On the basis of evidence from only 12 studies This finding was due to the absence
with substantial risk of bias, there is an absence of reliable evidence supporting of direct evidence of the positive
the positive effects of orthodontic therapy on patients’ periodontal status. effects of orthodontic therapy on
Evidence quality rating. Limited. periodontal health. Some evidence
suggests a small mean worsening of
Clinical question. Does contempo- cross-sectional studies in which periodontal health after orthodontic
rary orthodontic therapy affect peri- researchers compared untreated therapy.
odontal health? patients with patients who under- Conclusion. This comprehensive
Review methods. The authors went contemporary orthodontic search indicates an absence of reli-
conducted a comprehensive search treatment and in which the inves- able evidence for the positive effects
of the literature from January tigators conducted posttreatment of orthodontic therapy on patients’
1980 to June 2006, searching eight evaluations of periodontal health. periodontal status. The existing evi-
databases electronically and six The authors included studies dence does not support the claim
dental journals by hand. This involving both fixed and removable that orthodontic therapy results in
search identified 3,552 titles and treatment modalities, but they overall improvement in periodontal
abstracts, 12 of which were full excluded studies involving full- health.
articles that met the inclusion cri- banded and orthognathic surgery
The systematic review described here was
teria. The authors included one and distraction osteogenesis. The funded by the American Dental Association
randomized controlled trial (RCT), article describes the reasons for Foundation, Chicago.
three cohort studies and eight this exclusion.

Dr. Chung is a clinical assistant professor, Department of Pediatric Dentistry, College of Dentistry, University of Illinois at Chicago. She also is an evidence
reviewer for the American Dental Association.
Dr. Henwood is in private practice in San Antonio. He also is an evidence reviewer for the American Dental Association. Address reprint requests to Dr.
Henwood at 9240 Guilbeau Road, Suite 128, San Antonio, Texas 78250.

JADA, Vol. 140 http://jada.ada.org May 2009 575

Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
RESEARCH CRITICAL SUMMARIES
COMMENTARY
Importance and context. The American Asso-
ciation of Orthodontists (AAO)1 states in its litera-
ture that dental alignment achieved with ortho-
dontic therapy facilitates plaque removal and
reduces occlusal trauma, which improves manage-
ment of periodontal health. While this AAO publi-
cation suggests that orthodontic therapy may
have an indirect effect by allowing better manage-
ment of periodontal health, on the basis of this
systematic review, we find that a direct positive
association of orthodontic therapy with perio-
dontal health is yet to be demonstrated.
Strengths and weaknesses of the system-
atic review. The review authors used widely
accepted methods to identify studies addressing
the clinical questions posed. They established no
single a priori periodontal outcome measure. The
outcomes evaluated included both patient-
oriented and disease-related measures. The inclu-
sion and exclusion criteria were explained and
reasonable. The authors recognized the review’s
limitations: the low number of included studies,
a variety of measured outcomes and a high risk
of bias.
Strengths and weaknesses of the evi-
dence. The pool of 12 studies constitutes a weak
body of evidence; 11 studies were cohort and
cross-sectional and one was an RCT. The studies
differed in the kind of periodontal outcomes that
were assessed, although there were enough simi-
larities for the investigators to make preliminary
conclusions. Overall, the authors of this review
found little evidence to support any positive
periodontal effects of orthodontic therapy. In fact,
576 JADA, Vol. 140 http://jada.ada.org May 2009
Copyright © 2009 American Dental Association. All rights reserved. Reprinted by permission.
they found some evidence of negative periodontal
effects of orthodontic therapy.
Implications for dental practice. Although
the existing evidence comes from poorly designed
research with a substantial risk of bias, it sug-
gests that orthodontic treatment may slightly
increase the risk of developing periodontal dis-
ease, including alveolar bone loss, periodontal
pocketing and gingival recession. The strongest
evidence in establishing a relationship between
orthodontic therapy and periodontal conditions is
a randomized clinical trial that compared peri-
odontal status among people who had or had not
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received orthodontic therapy. The authors stated
that they included RCTs; however, they included
only one, and its relevance as a basis for com-
parison may be questioned. In it, the treatment
lasted only three months, whereas the norm for
orthodontic treatment duration is 12 to 18 months.
Further research is needed to assess the associa-
tion between orthodontic therapy and periodontal
health. ■
Critical Summaries is supported by grant 1 G08 LM008956-01A2
from the National Library of Medicine and the National Institute of
Dental and Craniofacial Research.
These summaries, published under the auspices of the American
Dental Association Center for Evidence-based Dentistry, are prepared
by practitioners trained in critical appraisal of published systematic
reviews who work under the mentorship of experts. The summaries are
not intended to, and do not, express, imply or summarize standards of
care, but rather provide a concise reference for dentists to aid in under-
standing and applying evidence from the referenced systematic review
in making clinically sound decisions as guided by their clinical judg-
ment and by patient needs.
For more information on the evidence quality rating provided above
and additional critical summaries, please visit “http://ebd.ada.org”.
1. American Association of Orthodontists. Want a beautiful smile? St.
Louis: American Association of Orthodontists; 2006.