Davis, S. M., Plonka, A. B., Fulks, B. A., Taylor, K. L., & Bashutski, J. (2014).

Consequences of orthodontic treatment on periodontal health: Clinical and microbial

effects. Seminars in Orthodontics, 20(3), 139–149. doi:10.1053/j.sodo.2014.06.002

Consequences of orthodontic treatment on

periodontal health: Clinical and microbial
effects
Steven M. Davis, DDS, MS,1 Alexandra B. Plonka, DDS,1 Brent A. Fulks, DDS,2
Kyle L. Taylor, BS,1 and Jill Bashutski, DDS, MS1

Orthodontic therapy is accomplished by inducing bone turnover in order to

move teeth within the alveolus. In addition, orthodontic appliances hinder
oral hygiene effectiveness and increase plaque accumulation. Therefore, it is
important to examine how these changes influence periodontal health. Our
current understanding is that orthodontic therapy influences the periodon-
tium by transiently changing the microbial environment and altering
periodontal clinical parameters such as attachment loss and probing depth.
However, there are minimal long-term consequences except in a small subset
of at-risk patients. High plaque index, subgingival encroachment of the
cervical margins of bands, deep probing depths, and length of orthodontic
treatment are several risk factors that can significantly increase the risk of
long-term attachment loss in patients undergoing orthodontic therapy.
Adults may experience fewer negative periodontal effects than children and
adolescents, provided they are periodontally stable when orthodontic
therapy is initiated. Careful consideration of daily oral hygiene, regular
maintenance, and monitoring of periodontal status to maintain stability are
critical in successful orthodontic treatment in adult populations. This review
examined specific aspects of orthodontic treatment and periodontal health,
including differences in responses between adults and children, factors that
can influence these parameters, identifying at-risk patients, and post-
treatment responses. (Semin Orthod 2014; 20:139–149.) & 2014 Elsevier
Inc. All rights reserved.

Introduction mechanism of action of moving teeth involves

O
creating an area of bone turnover adjacent to
rthodontics and periodontics have a com-
teeth that could potentially increase the short-
plex relationship within the mouth. Proper
term risk of losing attachment in that area. In
alignment of the dentition facilitates good oral
addition, the patient population undergoing
hygiene,1 although the process of straightening
orthodontic therapy is changing, with more adult
teeth through orthodontic therapy may have
patients pursuing orthodontic treatment. As a
negative effects on the periodontium through
result, the relationship between periodontics and
direct gingival irritation and compromised
orthodontics is becoming even more important
oral hygiene effectiveness. Furthermore, the
to understand as these disciples are intersecting
1
clinically. This article will provide an overview of
Department of Periodontics and Oral Medicine, University of
orthodontic and periodontal concepts, along
Michigan, Ann Arbor, MI; 2Department of Orthodontics and
Pediatric Dentistry, School of Dentistry, University of Michigan, with an in-depth analysis of the effects of
Ann Arbor, MI. orthodontic therapy on the periodontium from a
Address correspondence to Jill Bashutski, DDS, MS, Department of clinical and microbiological perspective.
Periodontics and Oral Medicine, University of Michigan, 1011 North
University Ave, Ann Arbor, MI 48109-1078. E-mail: jillbash@
umich.edu Overview of orthodontic therapy
& 2014 Elsevier Inc. All rights reserved.
1073-8746/12/1801-$30.00/0 Orthodontic therapy involves placing controlled
http://dx.doi.org/10.1053/j.sodo.2014.06.002 forces on teeth in order to promote tooth

Seminars in Orthodontics, Vol 20, No 3 (September), 2014: pp 139–149 139

140 Davis et al
movement, using removable or fixed appliances.
Fixed appliances require the use of brackets or
bands to attach to the tooth to transfer the
required force. Bracket types vary greatly, with
differing materials, sizes, auxiliary attachments,
and designs available. Ligation methods also vary,
with traditional brackets requiring an elastomeric
ring or stainless steel ligature tie, while self-
ligating brackets have a ligation apparatus within
the bracket. Orthodontic bands, often used on
posterior teeth, also vary greatly, utilizing dif-
fering styles of hooks and tubes.
Properly controlled forces are critical to effi-
cient tooth movement. The most widely accepted
theory for tooth movement is the pressure–
tension theory.2–5 As the periodontal ligament is
deflected from an orthodontic force, local
changes in blood flow occur leading to bone
resorption on the pressure side and bone dep-
osition on the tension side. Optimal forces result
in frontal bone resorption. As the blood vessels
are compressed, hypoxia results, and cellular
mediators such as prostaglandins and cytokines
are released. These cellular mediators result in
metabolic changes in cellular activity, activating
both osteoclasts and osteoblasts. Heavy forces
may result in undermining resorption potentially
slowing the rate of tooth movement.6,7 As the
heavy forces occlude the blood vessels and cause
localized ischemia, tissue necrosis occurs. Cel-
lular activity must be recruited from outside the
region to remove the damaged tissue. This results
in less efficient tooth movement. Orthodontic
tooth movement results in both modeling and
remodeling of bone. Modeling occurs during the
movement phase, while remodeling occurs dur-
ing the retention phase.
Overview of periodontology
Bacterial plaque in a susceptible host is the main
etiology of periodontitis.8 Health, gingivitis, and
periodontitis are the three overarching dia-
gnostic categories used to diagnose and
determine appropriate treatment. A healthy
periodontal environment exhibits an osseous
crest, which is approximately 2 mm below the
cemento–enamel junction (CEJ), and the
absence of an inflamed gingival sulcus, epithe-
lium, and connective tissues.9,10
Superficial inflammation limited to the gingiva,
often considered defensive in nature, characterizes
gingivitis. In the early stages of gingivitis, the junc-
tional epithelium widens allowing plaque and bac-
teria to gain access to connective tissue (CT).11–13
Within 1 week of plaque accumulation, slight signs
of erythema are noticeable due to proliferation of
capillaries, and bleeding on probing may be evident
while gingival crevicular fluid (GCF) secretion is
increased. Established gingivitis is notable 2–3 weeks
after beginning of plaque accumulation where an
intense chronic inflammation reaction is observed.
In periodontitis, inflammatory destruction
becomes irreversible and is associated with loss
of attachment and supporting bone. Clinical
attachment level (CAL), defined as the location
of the base of sulcus relative to the CEJ, is
considered the best marker for periodontal
diagnosis and is an absolute sign of disease.14–16
Increases in probing depth, defined as the dis-
tance from the base of gingival sulcus to the free
gingival margin, are also associated with disease
but may be due to inflammation and, thus, are
not necessarily associated with irreversible
attachment loss. Clinically, the transition from
gingivitis to periodontitis often includes
common observable gingival changes such as
bleeding or exudate on probing, loss of
periodontal tissue support resulting in tooth
mobility, gingival swelling, erythema, and tooth
malposition.11,17
Chronic periodontitis is the most prevalent
periodontal disease in adults and rarely occurs in
children. Chronic periodontitis generally pro-
gresses slowly, and its destructive potential is con-
sistent with the amount of local etiologic factors
present including plaque and calculus.18 Con-
versely, aggressive periodontitis often presents in
younger patients, progresses rapidly, and is not
associated with local factors such as plaque and
calculus. Instead, specific pathogenic bacteria and
genetics have been implicated as key etiologic
factors in this disease.19,20
Microbiology of the periodontium
The dental plaque biofilm consists of bacterial
aggregates that adhere to teeth and oral struc-
tures, providing nutrients and protection from
host defenses for the stable climax community.21
Early colonizers primarily adhere directly to the
pellicle and have various intra- and intergeneric
coaggregation patterns. Of the early colonizers,
90% of the cells in plaque coaggregate with
 Consequences of orthodontic treatment on periodontal health
streptococci and/or actinomyces. Fusobacteria
are known to link the early and late colonizers,
which either nonspecifically adhere or do not
adhere to saliva-coated hydroxyapatite.22,21 Soc-
ransky et al.19 associated characteristic bacterial
complexes with states of periodontal health and
disease, which were color-coded according to
disease association. In health, biofilms consist of
early sulcus-colonizers, which are most com-
monly gram-positive facultative anaerobic rods
and cocci including Actinomyces and Veillonella
parvula (purple complex); Streptococcus species
(yellow complex); and Campylobacter concisus,
Eikenella corrodens, and Aggregatibacter actinomycete-
mcomitans type a (green complex).
Without adequate oral hygiene, increased
bleeding and gingivitis is associated with the
presence of orange complex species such Eubacte-
rium nodatum, Peptostreptococcus, Fusobacterium, Pre-
votella, and Campylobacter species.19 Initially, fila-
mentous and fusobacteria appear, sometimes
bridging early colonizers with less-adherent spe-
cies.22 Motile spirochetes and flagellated species
are observed after 4–9 days.23 Gram-negative
counts increase as health shifts to disease24 and
gingivitis develops within 15–21 days.25
In chronic periodontitis, gram-negative obligate
anaerobic rods dominate gingival flora.26 Porphyro-
monas gingivalis, Tannerella forsythia, and Treponema
denticola (red complex) are strongly associated with
deeper pockets and chronic periodontal disease.27
In periodontal maintenance patients who have
been successfully treated for chronic periodontitis,
the presence of P. gingivalis, spirochetes, and
motile rods is associated with future attachment
loss.25,28
Aggressive periodontitis is found in younger
patients with a familial aggregation and a pattern of
rapid attachment loss and destruction.8 Although
classically associated with A. actinomycetemcomitans
(Aa), increased P. gingivalis and other red and
orange complex bacteria may be found.29
Phagocyte abnormalities and elevated cytokines
are secondary features, and a robust serum
antibody response is found in localized forms of
the disease.8
Microbial effects of orthodontics on the
periodontium
Appliances encourage plaque accumulation and
the development of gingivitis.21,30 Bands, brackets,
141
and orthodontic wires present unique challenges
for hygiene, as these appliances create many food
and plaque traps.30–34 Interproximal care is much
more difficult, requiring floss to be threaded
beneath the wire for each tooth. This becomes a
time-consuming process that requires skill and
dexterity to complete. Additional accessories such
as coiled springs, tubes, steel lacing, and elasto-
meric chain can provide additional hygiene dif-
ficulties. Thus, the presence of orthodontic
appliances increases plaque retention, which
reduces the effectiveness of daily oral hygiene.30
Most studies report increased plaque index scores
(PI)31–34 within 1–3 months after appliance
placement.
As plaque communities persist, a shift from
aerobic to anaerobic bacteria occurs. This shift in
bacterial profile is consistent with one associated
with periodontal health to one typically asso-
ciated with active periodontitis. Microbial
changes begin within a short period of time after
orthodontic therapy is initiated and includes an
increase in periopathogenic bacteria including
spirochetes, fusiform bacteria, facultative anae-
robes, lactobacilli, and Prevotella intermedia.35–38
Several authors have established the timeline for
these microbial changes and found that within
12 days after orthodontic therapy is initiated,
changes in bacterial composition begin to
occur.33,39 At this time, a greater number of cocci
and motile rods can be found in orthodontic
patients compared to those without appliances.
By 6 weeks, the amount of cocci decreases,
whereas an increase in spirochetes and motile
rods is noted.39 By 3 months, bacteria associa-
ted with the red and orange complexes are
established.
Shifts in the microbial composition due to
orthodontic bands may be a result of decreased
plaque control but the appliances themselves
may also alter the microbial composition of the
mouth. Most commonly, this is due to the
microbial shift around subgingivally placed
orthodontic bands, which develop “red complex”
bacteria similar to that seen around overhanging
restorations.39
In adult patients previously treated for
periodontitis, the initial microbial composition
may be different from for younger adults with a
healthy periodontium presenting for ortho-
dontic therapy. Speer et al.40 found that bacterial
counts did not change over the course of
142
orthodontic treatment in periodontally stable
adult patients with a history of periodontitis.
However, bacteria associated with active
periodontal disease such as Campylobacter rectus,
Veillonella, Peptostreptococcus, Actinomyces viscosus,
and Bacterionema rothia increased significantly
above pretreatment levels within 6 weeks after
orthodontic treatment was initiated.40 However,
no permanent damage to the periodontium was
noted, even post-treatment in any of these
patients, and so the clinical significance of these
findings remains unknown.
Orthodontic appliances also increase the
likelihood that yeast is found in subgingival
biofilms, with one study reporting a three-fold
increase in the prevalence of yeast in patients
with orthodontic appliances versus those with-
out.41 The most frequent yeasts observed were
Candida albicans (47.2%) in both gingivitis and
periodontitis patients, and other yeasts included
C. parapsilosis, C. dubliniensis, C. tropicalis, C.
guilliermondii, C. sake, and Rhodotorula spp.41
Clinical effects of orthodontics on the
periodontium
The presence of periopathogenic bacteria elicits
an inflammatory response within the gingiva and
surrounding periodontium. An inflammatory
response to increased plaque accumulation then
occurs, with most studies reporting concomitant
increases in gingival index (GI)31–34,42 and
bleeding upon probing (BOP) or gingival
bleeding index (GBI)31,33,34,43 after orthodontic
appliances are placed. Table 131–34,42–48 sum-
marizes clinical changes that occur during active
orthodontic therapy. The type of orthodontic
appliance may influence the level of inflamma-
tory response as well. For example, Kim et al.49
Table 1. Change in Periodontal Parameters During Active Orthodontic Therapy
References PI
Zachrisson and Alnaes44 Not reported
Kloehn and Pfeifer45 Decreased
Karkhanechi et al.31 Increased
Sinclair et al.42 No change
Paolantonio et al.46 Decreased
Naranjo et al.33 Increased
Ristic et al.34 Increased
Lo et al.47 Decreased
Liu et al.32 Increased
van Gastel et al.43 Not reported
PI, plaque index; GI, gingival index; BOP, bleeding on probing; GBI, gingival bleeding index; PPD, probing pocket depth.
Davis et al
found higher BOP in banded sites compared
to bracketed sites. Most studies agree that
removable orthodontic appliances do not alter
the subgingival flora and that fixed appliances
affect the periodontium to a much greater
extent.50 However, despite initial increases in
plaque, inflammation, and bleeding, these
parameters may actually improve during treat-
ment. Ristic et al.34 found a peak in plaque
accumulation and other periodontal parameters
at 3 months followed by an overall decrease
between 3 and 6 months. In some cases, plaque
scores remained stable42 or ultimately decreased
during treatment.42,47,51 Sinclair et al.42 found no
major changes in plaque accumulation or
probing depth over 1 year of orthodontic
treatment. Lo et al.47 reported a significant
increase in PI at 2 weeks but a PI significantly
lower than baseline at 12 weeks.
Gingival inflammation and bleeding scores
followed similar trends. Paolantonio et al.51
found that orthodontic patients had a stable
number of plaque-positive sites over 3 years but a
significant decrease in sites with positive GBI.
This improvement may be attributed to the
increased focus on oral hygiene instructions by
the dental practitioner, along with an increased
number of dental visits to reinforce oral hygiene
instructions that occur during orthodontic
therapy. Alstad and Zachrisson52 demonstrated
the importance of improved oral hygiene aware-
ness for orthodontic patients in 1979. At the time of
appliance removal, orthodontically treated patients
had significantly lower plaque scores and number
of BOP sites versus patients who did not receive
orthodontic therapy or reinforcement of oral
hygiene instructions. Thus, it is important to be
aware that orthodontic therapy transiently
increases plaque accumulation and concomitant
GI BOP/GBI PPD
Not reported Not reported Increased
Not reported Not reported Not reported
Increased Increased Increased
Increased (bonded sites) Not reported No change
Not reported Decreased No change
Increased Increased No change
Increased Increased Increased
Decreased Not reported Not reported
Increased Not reported No change
Not reported Increased Increased
 Consequences of orthodontic treatment on periodontal health
inflammation, but that increased reinforcement of
oral hygiene can reduce this negative effect over
the course of orthodontic therapy.
With respect to probing depths, there is some
disagreement within the literature, with some
studies reporting no effect of orthodontics on
probing depth,32,33,42,51 and other studies dem-
onstrating increased probing depths as a con-
sequence of orthodontic therapy.31,34,43,48 In any
case, most authors agree that the deeper probing
depths observed in orthodontic patients are most
likely attributed to pseudopockets or deeper
probe penetration into weakened connective
tissues, as opposed to attachment loss of the
supporting periodontium.48 Deep pseudo-
pockets will form in children due to moderate
hyperplastic gingivitis within 1–2 months of
appliance placement, and this will occur most
commonly at interproximal and posterior sites.53
Many theories exist to explain this including
increased food impaction, poor oral hygiene,
and mechanical or chemical irritation.45,53 Cases
of hyperplastic or hypertrophic gingivitis have
been reported at an estimated rate of one every
10.54 One study demonstrated that there were
four times as many hyperplastic sites inter-
proximally versus the mid-crown region, and
five times as many hyperplastic areas on pre-
molars and molars versus incisors and canines.45
In general, the severity of pseudopocket
formation typically correlates with poor oral
hygiene, although mild interproximal changes
are still found in patients demonstrating good
oral hygiene. It is important to note, though, that
while orthodontics can increase plaque accu-
mulation, children with malocclusion still have
greater plaque levels than children with ortho-
dontic appliances.55 These changes manifest histo-
logically as mild to moderate chronic inflammation
with increased plasma cells, lymphocytes, and other
immune cells; gingival hyperplasia; and pocket
epithelial proliferation. In summary, gingival
enlargement explains some of the reported
increases in probing depths, which are not
related to attachment loss. This inflammation is
noted even in patients with good oral hygiene and
is resolved as early as 48 h after band removal,
suggesting that the appliances themselves have an
influence on periodontal health unrelated to
plaque-induced periodontal disease.56
Attachment loss and bone loss as a con-
sequence of orthodontic therapy is of greater
143
concern, although this appears to be rare relative
to increases in probing depth. Attachment loss
may occur as a result of tooth movement itself, or
due to indirect effects of periopathogenic bac-
teria growth. During light force orthodontic
movement, increased bone turnover around
teeth occurs and the PDL undergoes ischemia,
which may increase the potential for a negative
effect on the supporting bone and soft tissues.57
While in theory this may increase susceptibility to
periodontal breakdown, most studies evaluating
the effect of tooth movement have shown that
this will only occur in the presence of active
inflammation due to periodontitis.58
Of studies that examined if orthodontic
therapy causes attachment loss, most found a
clinically insignificant increase in attachment loss
when compared to patients without orthodontic
treatment.44,52,46 Zachrisson and Alnaes per-
formed cross-sectional CEJ-to-base of pocket
measurements on orthodontic and control
patients and found small (mean = 0.3 mm) but
statistically significant increases in attachment
loss in orthodontic patients.44 Notably, a small
percentage of these patients did develop
significant attachment loss of 1–2 mm or more.
In contrast, Paolantonio et al.46 found no
increases in attachment loss greater than or
equal to 2 mm, although small negative effects
were noted. Finally, Alstad and Zachrisson52
found no statistically significant differences in
attachment levels between patients treated with
or without orthodontic therapy. With respect to
bone loss, orthodontic patients have been shown
to experience greater bone loss than patients
who do not undergo orthodontic therapy,
although this difference may not be clinically
significant. One study found that orthodontic
patients experienced 0.23 mm more bone loss
measured radiographically and that closed
extraction spaces, retracted canines, and serial
extraction cases were at higher risk for bone
loss.59
Consequently, it can be concluded that most
of the time, orthodontic therapy does not cause
irreversible harm to the periodontium. However,
in a small subset of around 10% of patients,
orthodontic therapy may have adverse effects on
attachment loss.44 The key is to understand
the factors that place patients in this high-risk
category so that appropriate management strat-
egies can be implanted to prevent harm. Several
144 Davis et al
risk factors have been evaluated that predispose a
patient to irreversible periodontal attachment
loss and include high plaque index, subgingival
encroachment of the cervical margins of bands,
deep probing depths, and length of orthodontic
treatment.60
Orthodontic therapy may cause or exacerbate
gingival recession through the movement of
teeth, as well as the effects of orthodontic app-
liances on the gingiva. A recent systematic review
suggested that tooth movement out of the
alveolar housing may be associated with a higher
tendency for developing gingival recession,
although robust evidence is lacking and the clinical
significance of the recession may be minimal.61 In
addition, certain situations appear to be high risk
for gingival recession and include facial tooth
movement and thin keratinized gingiva. In cases
where gingival recession is present, or it is
suspected that gingival recession may occur as a
result of therapy, the options are to perform soft
tissue grafting procedures prior to, or after,
orthodontic therapy. There are no randomized
controlled trials evaluating the optimal time to treat
gingival recession, although the available evidence
suggests that augmenting gingiva prior to initiating
orthodontic therapy provides acceptable results.62
The process of placing the orthodontic
appliances may also cause gingival irritation
including erosion, contusions, and ulceration,
which are correlated with oral hygiene effec-
tiveness.55 Commonly used etching and bonding
materials may cause transient chemical burns or
allergic reactions along the gingiva.63,64 Excess
cement and composite during bonding and
banding, or flash, may lead to gingival irritation
and increased plaque accumulation.65
Differences in response to orthodontic
therapy between adults and children
An increasing number of adult patients are
pursuing orthodontic therapy, and frequently
these patients will have a history of attachment
loss and periodontal therapy. In order to assess if
orthodontic therapy presents a higher risk for
patients with previous periodontal disease, Boyd
et al.66 compared the effects of orthodontic
therapy in three patient groups: adolescents
with normal periodontal tissues, adults with
normal periodontal tissues, and adults with a
history of periodontal disease that were
previously treated and stabilized. Patients who
had a history of chronic periodontitis had
received comprehensive periodontal treatment
prior to orthodontic treatment and also received
periodontal maintenance every 3 months during
treatment. The outcomes of this study showed
there were no differences in the adult groups
throughout orthodontic therapy with respect to
inflammation, plaque, or attachment loss. How-
ever, the adolescent group had significantly more
inflammation and supragingival plaque than the
adult groups, and poor oral hygiene correlated
with significant attachment loss. Other studies
have shown that orthodontic tooth movement is
contraindicated if significant marginal bone loss
is observed due to periodontal disease, or if the
disease is active.67,68 These findings support the
idea that adult patients are appropriate candi-
dates for orthodontic therapy, as long as any
periodontal disease has been appropriately
treated prior to initiating orthodontic therapy
and plaque control is adequate.
A shift toward periopathogenic bacteria
occurs within days of orthodontic therapy ini-
tiation and is sustained in children for the
duration of treatment but not necessarily in
adults. One study compared microbial changes
in adults and children undergoing orthodontic
therapy.69 Microbial changes associated with
periodontal disease peaked at 6 months of
therapy and were sustained throughout
treatment in children but not in adults. Thus,
adults and children exhibit different clinical and
bacterial changes with orthodontic therapy, with
changes appearing more transient in an adult
population. Several reasons may explain these
differences.37,39,66,69,70 Adults are more likely to
have had periodontitis, resulting in attachment
loss and, thus, allowing appliances to be placed
further away from the existing gingival attach-
ment. In addition, adults are not undergoing
hormonal changes associated with puberty and,
as a result, have less propensity for bacteria such
as P. intermedia, and associated inflammation.
While both adults and children are theoretically
susceptible to periodontitis, orthodontic therapy
may confer less risk in adults due to their ability
to exercise better plaque control in a less
hyperinflammatory phenotype. In adults with
active periodontal disease, or if severe bone loss is
present at the time of therapy initiation, ortho-
dontic therapy may accelerate disease
 Consequences of orthodontic treatment on periodontal health
progression, even resulting in tooth loss.
Research suggests that adults and children do not
respond in the same way to orthodontic therapy
and that adults may experience fewer negative
periodontal effects, as long as they are perio-
dontally stable when orthodontic therapy is
initiated.
Aggressive periodontitis typically manifests in
young patients and is a major consideration in
orthodontic therapy due to its propensity for
inducing rapid periodontal destruction. In
patients diagnosed with aggressive periodontitis,
orthodontic therapy has been conducted suc-
cessfully, although treatment modifications are
recommended, including initiating therapy only
after periodontal stability is achieved.71 Ortho-
dontic therapy induces high numbers of
periopathogenic bacteria within 6 months of
appliance insertion.72 Therefore, microbial and
clinical monitoring is essential, along with
aggressive antimicrobial therapy to limit clinical
inflammation when indicated.72 However, patients
with a history of aggressive periodontitis can be
successfully treated with orthodontic therapy,
which under controlled conditions does not
result in further periodontal destruction.73
Treatment modifications that affect
clinical and microbiological periodontal
parameters during orthodontic therapy
Maintaining excellent oral hygiene during
orthodontic therapy appears to be the most
effective way to prevent periodontal breakdown.
Ideally, orthodontic treatment should only be
done on patients that are motivated and capable
of proper brushing and flossing. However, as
many orthodontic patients are adolescents,
patient motivation and hygiene may not always be
optimal. Patients undergoing orthodontic ther-
apy have more frequent dental visits, allowing
regular reinforcement of oral hygiene. There are
many studies demonstrating that frequent oral
hygiene instruction during orthodontic therapy
improves oral hygiene effectiveness, sometimes
better than pretreatment levels.56,74–76 Providing
oral hygiene instructions prior to beginning
treatment, and hygiene reinforcement through-
out treatment, is extremely important. Similar to
periodontal patients, the mainstay of oral hygiene
remains brushing and flossing. Proper brushing
technique, with focus between the gingiva and
145
fixed appliances, should be demonstrated to the
patient. Studies evaluating different types of
toothbrushes have been done. Ho and Nieder-
man77 demonstrated more improvement in
gingivitis scores in children brushing with a
Sonicare toothbrush versus a manual tooth-
brush. Erbe et al. have evaluated the efficacy of
different toothbrushes on plaque removal,
comparing an electric toothbrush with an
orthodontic head, a standard electric tooth-
brush, and a manual toothbrush. Plaque
removal was best with the electric toothbrush
with an orthodontic head, while both the electric
toothbrushes were significantly better than the
manual toothbrush.78 The use of adjunctive
hygiene instruments can also be encouraged.
Floss threaders may be used to ease placement of
the floss beneath the wire. A proxibrush, often
used in periodontics for interproximal care, can
also be adapted for use cleaning brackets and
beneath the wire. Water flossers may also be used;
however, they should remain an adjunct to
proper brushing and flossing. Brushing and
flossing, if done properly, should provide
adequate plaque removal to maintain healthy
teeth and gingiva. In addition, chemical means to
control plaque such as fluoride, chlorhexidine,
xylitol, and triclosan may also be used as adjuncts
to decrease plaque levels.79,80
Materials and coatings have been used in
various modifications to reduce the bacterial
retention properties of fixed orthodontic devi-
ces.81 Different approaches to anchoring arch
wires, such as elastomeric rings and steel ligature
ties, have been shown to have no differences with
respect to bacterial retention.82 Similarly, no
difference in plaque retention has been observed
with different fixed orthodontic devices.49
The use of bands versus bonded brackets may
affect the periodontal response to orthodontic
therapy. Brackets prevent easy access to inter-
proximal cleaning, whereas bands are in close
proximity to the gingival margin and may cause
direct gingival irritation and plaque accumu-
lation. van Gastel et al.83 reported faster increases
in PD, BOP, and GCF flow in bonded sites versus
banded sites, attributing this difference to the
wires hindering interproximal cleaning. Con-
versely, Kim et al.49 found increased BOP and
deeper pockets around bands versus brackets but
no difference in plaque levels. This study also
found no significant differences in periodontal
146
parameters when comparing bands placed supra-
or subgingivally. Several other studies reported
that subgingival placement of a band does
promote periopathogenic bacterial growth. In
addition, the possibility of excess cement around
the bands will cause additional plaque accu-
mulation and gingival irritation.84,85 Another
study reported that banded sites had twice the
number of bleeding sites versus bonded sites,43
although a different study reported no difference
in bleeding between banded and bonded
patients.52 Both bands and brackets, therefore,
have important but different effects on the
periodontium.
Post-treatment clinical and microbial
changes
Periodontal health is negatively affected by
orthodontic therapy during active treatment, but
these effects are largely reversible with no long-
term increased risk for periodontitis
(Table 2).32,43,45,86–88 After orthodontic therapy
is completed, the bacterial profile shifts back to
pretreatment levels, although slight, clinically
insignificant changes in periodontal clinical
parameters such as probing depth and attach-
ment loss remain.46,59 In a small subset of the
population, these changes can be significant.44
Plaque retention from fixed appliances and
the concomitant inflammation resolves quickly
after orthodontic therapy is terminated and does
not affect long-term gingival or periodontal sta-
tus or health.87 As previously stated, often
bacterial counts rise with the increased plaque
accumulation immediately following placement
of fixed orthodontic appliances; however,
Table 2. Change in Periodontal Parameters Post-
orthodontic Therapy
References PI GI BOP/GBI
Kloehn and Decreased Not Not Decreased
Pfeifer45 reported reported
Sallum Decreased Decreased Not Decreased
et al.86 reported
Liu et al.32 Decreased Decreased Not Decreased
reported
van Gastel Not Not Decreased Decreased
et al.43 reported reported
PI, plaque index; GI, gingival index; BOP, bleeding on
probing; GBI, gingival bleeding index; PPD, probing pocket
depth.
Davis et al
E. corrodens, Fusobacterium nucleatum, T. denticola,
and C. rectus have also been found at lower levels
post-orthodontic therapy when compared to
pretreatment levels.88 Upon completion of
orthodontic treatment in addition to pro-
fessional and daily oral hygiene, resolution of
gingival inflammation and enlargement has been
noted within 30 days after the removal of
orthodontic appliances.86 Resolution of microbial
changes following orthodontic treatment typically
resolves within 3 months of the removal of
appliances.86,88
Clinical periodontal parameters such as
plaque, gingival inflammation, bleeding, and
probing depths usually improve with appliance
removal, indicating periodontal changes induced
by orthodontic changes are generally rever-
sible.32,43,45,86 One study found an increased
prevalence of mild to moderate periodontitis in
adults who were treated with orthodontic therapy
as children, although most studies agree that
previous orthodontic therapy does not sig-
nificantly influence future development of
periodontal disease.87
Conclusion
Malocclusion may negatively influence perio-
dontal health, justifying the need for orthodontic
therapy. Orthodontic therapy may have a negative
effect on periodontal health, and this is especially
apparent in patients with inadequate oral
hygiene. Orthodontic therapy has both direct and
indirect effects on the periodontium. Perhaps,
the most notable effect is that on oral hygiene.
The presence of brackets and wires compromises
oral hygiene, but contradictorily, the increased
frequency of dental visits and concomitant
emphasis on oral hygiene instructions sometimes
improves overall hygiene effectiveness. Fur-
thermore, orthodontic therapy initiates increased
PPD bone turnover around teeth, leaving them sus-
ceptible to irreversible bone and attachment loss
when in the presence of inflammation. In any
case, the duration of orthodontic therapy is small
compared to the time for development of
periodontitis.
Reported long-term adverse effects of ortho-
dontics on the periodontium are minimal for the
average patient, and orthodontic therapy does
not appear to significantly affect periodontal
conditions in the future. There appears to be a
 Consequences of orthodontic treatment on periodontal health
small percentage of patients for whom ortho-
dontic therapy confers a risk of significant and
irreversible periodontal destruction. The key to
successful management is identification of risk
factors that increase periodontal disease sus-
ceptibility, including poor oral hygiene, active
periodontitis, and significant attachment loss.
Adults undergoing orthodontic therapy have
different clinical and microbiological responses
to therapy compared to children, but both can be
treated with minimal effects on periodontal
health.
The purpose of this review was to evaluate the
clinical and microbial effects of orthodontic
therapy on the periodontium. This review
examined specific aspects of orthodontic treat-
ment and periodontal health, including differ-
ences in responses between adults and children,
factors that can influence these parameters,
identifying at-risk patients, and post-treatment
responses.
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