Long-term effects of

orthodontic treatment on
periodontal health Dr Sadowsky

Cyril Sadowsky, B.D.S., MS., and Ellen A. BeGole, Ph.D.

Chicago, 111.

The periodontal health of a group of ninety-six patients who had recei\~cd

comprehensive fixed-appliance orthodontic treatment during adolesteru~e between l-7
and 35 years previously was evaluated. Comparisons were made with a group oj 103
adults who were similar with regard to race, sex, age, socioeconomic status, dental
awareness, and oral hygiene status but had malocclusions that had not been
orthodontically treated. There were no statistically sign&ant differences in the
general prevalence of periodontal disease between the two groups. However, more
detailed analysis revealed that the orthodontic group had a greater prevalence of mild
to moderate periodontal disease in the maxillary posterior and mandibular anterior
regions of the mouth, as compared to the control group. The results suggested that
orthodontic treatment in adolescence is not a major factor in determining the
long-term periodontal health status. No sign$cant amount of either damage or henejit
to the periodontal structures could be directly attributed to orthodontic therapy.
Conversely, the lack of orthodontic therapy in adolescence does not uppear to
injluence subsequent development or nondevelopment oj’periodontal disease in adults.

Key words: Orthodontic treatment, periodontal disease, tissue destruction index,

mucogingival problems, malocclusion

I t is widely believed that an important rationale for performing orthodontic

treatment is to promote the health of the periodontium, thereby enhancing longevity of the
dentition. ’ 3 2 It is therefore assumed that adults with untreated malocclusions would be
subject to a greater prevalence of periodontal disease than if their malocclusions had been
corrected orthodontically. The relationship between malocclusion and periodontal disease
has received much attention in the literature, with little support for such a relationship.
Conversely, it has been maintained that orthodontic treatment may have some adverse
effects on the gingival and periodontal tissues which may hasten or promote periodontal
breakdown in later life.3-5 Most of the studies on the effects of orthodontic treatment on
periodontal health have been concerned with the effects during treatment and up to a few
years after treatment, with no long-term follow up. Also, most studies did not make use of
a control group, which would be desirable to permit interpretation of the findings.
The objective of this study was, therefore, to evaluate the periodontal health of a large
group of patients who had received comprehensive orthodontic treatment during adoles-

Fromthe Departmentof Orthodontics,Universityof Illinois Collegeof Dentistry.

Supportedby the NationalInstituteof DentafResearch,Bethesda,Md., ContractNo. 1 DE 72401.
156 0002-9416/81/080156+17$01.70/0 @ 1981 The C. V. Mosbv Co.
Volume 80
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Orthodontic treatment and periodontal health 157

cence at least 12 years previously and to compare the periodontal health of this group with
that of a group of similar adults who had malocclusions that had not been orthodontically
treated. Specifically, the following questions were raised: (1) Is orthodontic treatment
beneficial, detrimental, or not significant in the long-term periodontal health status? (2)
Can the status of the periodontal tissues of previously treated orthodontic patients be
related to the length of treatment, use of maxillary headgear, or extraction of teeth as part
of the orthodontic therapy?
Review of the literature
Zachrisson and co-workerFg reported on a study of fifty young patients with Class II,
Division 1 malocclusions treated for an average of 19 months with extraction of four first
premolars. The health of the periodontal tissues was evaluated periodically during treat-
ment and up to 2 years after treatment and compared to a similar control group of
teenagers. In spite of good oral hygiene, a generalized moderate hyperplastic gingivitis
was evident 1 to 2 months after appliance placement. This condition persisted throughout
the treatment period and then improved during the first month after appliance removal.
Similar changes in the gingival tissues have been reported by many other authors since
Stuteville in 1937, but the observations were limited to the period of active treatment or
immediately after appliance removal. ‘O-*OIn Zachrisson’s study, however, after 2 years of
posttreatment follow-up, the orthodontic group demonstrated a slightly increased loss of
periodontal attachment and alveolar bone as compared to the untreated control group, but
this was considered to be within acceptable limits. However, approximately 10 percent of
the orthodontic patients demonstrated a more significant amount of loss of attachment and
marginal alveolar bone loss. It should be realized that the cases studied involved severe
malocclusions requiring extensive tooth movement.
In a more recent longitudinal study by Alstad and Zachrisson,2’ conducted on thirty-
eight adolescent patients whose Class I and Class II malocclusions had been treated with
premolar extractions and compared to a similar group of subjects with almost ideal
occlusions, no difference was found in the loss of periodontal attachment up to 5 months
after treatment. The orthodontic patients, however, did participate in an oral hygiene
program during treatment. Similarly, Kloehn and Pfeifer** evaluated the gingival health
and periodontal and alveolar bone support in fifty consecutively treated orthodontic ex-
traction and nonextraction adolescent patients during and up to 4 months after treatment.
In addition to noting a marked decrease in the hyperplastic gingivitis within 48 hours after
the conclusion of treatment, their findings indicated that orthodontic treatment did not
cause irreversible periodontal destruction. Trossello and Gianellf3 also reported only
minor differences in the health of the periodontal tissues and alveolar bone in a group of
thirty female patients between 18 and 25 years of age at least 2 years after orthodontic
treatment, as compared to a similar group of subjects who had never received orthodontic
therapy.
Orthodontic treatment, however, has been indicted for producing a large amount of
periodontal disease by Pritchard,j who reported a study of 100 consecutive former orth-
odontic patients treated with four premolar extractions, who were referred to him for
periodontal treatment. He did acknowledge the bias of his sample but succeeded in
alerting orthodontists to potential periodontally hazardous situations after orthodontic
treatment, particularly in closed extraction sites. The incidence and possible problems of
 interdental clefts in premolar extraction sites were investigated by Robertson and col-
leagues” in a group of forty patients at least 1 year after active orthodontic treatment.
Areas of gingival invagination occurred in 35 percent of the patients studied and impaired
the ability of the patients to keep the area clean. Using a standardized panoral radiographic
technique, Tirk and associateszs observed frequent unfavorable reactions of the alveolar
bone in patients undergoing orthodontic treatment. The radiographic technique, however,
did not permit quantitative assessments, and not enough patients were available for statis-
tical evaluation. Trossello and Gianelly’” also reported some differences in the distribution
of gingival clefting and recession in the orthodontically treated group in the lower incisor,
maxillary canine, and first molar areas. Sperry and co-authors’” reported increased labial
gingival recession in maxillary and mandibular anterior teeth as a consequence of exces-
sive dental compensations in Class III malocclusions treated orthodontically. Similarly,
Pearsoni reported significant gingival recession in the lower incisor region in only a small
percentage of forty-seven orthodontically treated cases as compared to a control group of
twenty-seven untreated adolescents. There was no correlation between various incisal
movements and the degree of gingival recession.
Dorfman” studied the mucogingival changes resulting from mandibular incisor tooth
movements in 1,150 completed orthodontic cases. He found that a small percentage of
cases ( 1.3 percent) showed a decrease in width of keratinized gingiva. These were statisti-
cally correlated with the magnitude and direction of tooth movement.
Klar” reported significantly more mucogingival problems (42.5 percent) in a group of
forty orthodontically treated subjects at least 5 years after treatment as compared to a
control group with relatively normal occlusions (12.5 percent).
A number of papers have been written on the relationship between malocclusion and
periodontal disease. The samples used and the methods of evaluation have varied, and
results have been conflicting and contradictory. A number of studies have reported an
increased prevalence of periodontal disease in the presence of malocclusion. Hellgren’”
found that gingivitis was significantly more severe when crowding of teeth was present.
Poulton and Aaronsot?’ and Bilimorii” found a significant relationship between incisor
crowding when they used the Occlusal Feature Index and the periodontal status as evalu-
ated by the peridontal index of Russell. Similarly, Buckley”Z reported a small but sig-
nificant relationship between lower incisor crowding and peridontal disease. In a later
study, Buckley”” observed that plaque was the primary etiologic agent in gingival disease,
but when the amount of plaque and gingival disease was low, a statistically significant
relationship was found between irregular teeth, plaque, and gingival disease. Sandali
also concluded that dental irregularities, at least in the mandibular anterior segment, have
a deleterious effect on the periodontal condition. Jacobson and Linder-Aronso@ found an
association between crowding and gingivitis in mouth breathers but not in nose breathers.
In contrast, a large number of studies did not reveal a relationship between various
aspects of malocclusion and periodontal disease. 36--j4However, situations of severe over-
jet and overbite did show an increased trend toward more periodontal disease, as reported
by Gould and Picton38 and Geiger and associates. 48Maxillary anterior teeth tended to be
more mobile when the overjet was greater than 6 mm. The mobility of mandibular incisors
was also related to increased overjet.‘” Labial gingival recession of mandibular incisors
has been found to be related to linguoversion, although in cases of severe overjet mandibu-
lar incisors in labioversion had slightly more disease.j’ It therefore appears that there is an
Volume 80
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Orthodontic treatment and periodontal health 159

abundance of evidence that does not show a relationship between malocclusion and
periodontal disease, except in particular more extreme situations.
Materials and methods
Selecrion of the study groups. Letters were sent to approximately 1,500 former orth-
odontic patients treated by six orthodontists in the Chicago metropolitan area. All patients
had adequate pre- and posttreatment study models and had been treated with upper and
lower fixed edgewise appliances at least 12 years previously, prior to adulthood. One
hundred sixty-two of these former orthodontic patients responded and subsequently signed
informed consent forms for an examination of their mouths and follow-up orthodontic
records. In order that possible influencing of the volunteers could be minimized, no
mention was made of the specific purpose of the examination. Because of problems with
scheduling, only 96 out of the 162 orthodontically treated former patients who consented
to participate in the study were finally examined and formed the experimental group.
In order to identify a suitable control group, letters requesting adults with untreated
malocclusions to volunteer for an initial mouth examination as part of a research study on
the oral health of adults were sent to academic personnel at the University of Illinois in
Chicago and to parents of orthodontic patients in four private practices in the Chicago
metropolitan area. In addition, articles appeared in the University of Illinois press and the
local press of the Chicago suburbs. Parents of patients undergoing treatment in the De-
partment of Orthodontics, University of Illinois College of Dentistry, were also screened
with respect to general background characteristics and severity of malocclusion. Subjects
suitable for inclusion in the control group had to satisfy the following criteria:
1. There was no history of orthodontic treatment.
2. Only Caucasians were selected, since that was the only racial group that happened
to be represented in the orthodontic group. Out of the total of 298 subjects screened, 32
were excluded because they did not meet this criterion.
3. All subjects had to be between 25 and 55 years of age, since almost the entire
orthodontic group was within this age range. Out of 298 subjects screened, 25 were
excluded because they were not in this age range.
4. A minimum of twenty natural teeth had to be present in an arrangement to permit
adequate evaluation of the occlusion. Out of 298 subjects screened, 16 were excluded
because they did not meet this criterion.
5. A malocclusion had to exist, as judged by scores derived from the subjective
clinical recordings to eliminate subjects with minor deviations from normal occlusions.
Out of a total of 298 subjects screened, 34 were excluded because their occlusion scores
were determined to be within the range of minor deviations.
6. A dental awareness score of 6 to 9 based on:
(1) Regularity of dental visits: irregularly = score 1; every 12 months = score 2;
every 6 months = score 3.
(2) Regularity of tooth brushing: irregularly = score 1; once daily = score 2;
twice daily = score 3.
(3) Use of dental floss: never = score 1; irregularly = score 2; once daily =
score 3.
Information regarding dental awareness was obtained by questionnaire and was used
to eliminate subjects with poor dental awareness, since it was apparent after examining the
first 75 subjects in the orthodontically treated group that they had a high level of dental
awareness and exhibited generally low plaque and gingival index scores. Out of a total of
298 subjects screened, 31 were excluded for not having a dental awareness score of 6 to 9,
based on the above criteria. Since it is generally accepted that bacterial plaque is the
primary etiologic factor in periodontal disease, it was important to control plaque as a
variable, in addition to other variables, in order to attempt to answer the questions posed
in this study. An attempt was made to identify a control sample that would be as similar as
possible to the orthodontic group, except for the presence of a malocclusion that had not
been treated orthodontically.
On the basis of all of these criteria, 159 subjects were identified as being suitable for
inclusion in the control group. For various personal and logistic reasons unrelated to
sample selection, 103 subjects were finally examined.
Datu collection. The subjects representing the two groups were given a comprehensive
clinical examination, which included various diagnostic records. The examinations were
performed in the orthodontic clinic and in private dental offices in the Chicago area. A
questionnaire was completed to record general background characteristics, including med-
ical and dental history. One of two periodontists performed the following periodontal
examination at six areas around each tooth, and the data were recorded on specially
designed coding forms for subsequent key punching and computerization:
1. Plaque Index as described by Silness and Liiej” was recorded independently at six
areas around each tooth.
2. Gingival Index as described by Lee and Silnes$” was similarly scored at six areas
around each tooth.
3. Periodontal pocket depth was recorded, in millimeters, from the deepest penetra-
tion of the probe to the free gingival margin for each tooth in the six areas previously
mentioned, by means of a thin Nordent* N22 periodontal probe.
After computerization of these linear depth recordings, the computer generated a
coded probe score of pocket depth for each of the areas of each tooth, as described by
Geiger and associates.4” Each of the six areas of each tooth was also scored with the coded
probe to reflect gingival enlargement and, separately, gingival recession from the free
gingival margin to the cementoenamel junction.
A specially designed computer program? was used according to the method of Geiger
and co-workers4” to compute a Tissue Destruction Index ranging from 1 to 6 for each
tooth. Tissue Destruction Index scores of 1 or 2 were considered to be normal or border-
line between health and disease.
4. Width of attached gingiva was measured clinically to the nearest 1 mm. with a
periodontal probe on the facial aspect of each tooth at the mesiofacial and distofacial line
angles and midway between the two, from the free gingival margin to the mucogingival
junction. The actual amount of attached gingiva was computed by subtracting the depth of
the gingival sulcus from the above clinical measurement.
Data analysis. In order to evaluate similarity of the experimental and control groups,
statistical comparisons were carried out. Chi-square tests were performed for sex, socio-
economic variables (occupation, education, income), and dental awareness variables

*Nordent Manufacturing, Inc., Elk Grove Village, 111

Wetails available on request.
Volume 80
hknber 2
Orthodontic treatment and periodontal health 161

Table 1. Plaque index in orthodontic and control groups

Orthodontic Control

Mean S.D. Mean S.D. t value

Total mouth 0.97 0.46 1.05 0.47 -1.31

Maxillary posterior right 0.97 0.52 1.06 0.48 -1.36
Maxillaryanterior 0.67 0.46 0.80 0.56 -1.89
Maxillary posterior left 0.93 0.51 1.07 0.52 -1.83
Mandibular posterior left 1.10 0.46 1.18 0.52 -1.12
Mandibular anterior 1.03 0.57 1.02 0.51 0.25
Mandibular posterior right 1.10 0.50 1.18 0.50 -1.23

(regularity of dental visits, toothbrushing, flossing habits). From the three variables repre-
senting dental awareness, a single dental awareness score was computed and tested statis-
tically by Student’s t test. In addition, summary data from plaque index recordings (total
mouth score and six segments) were compared for the orthodontic and control groups by
means of t tests.
The periodontal condition on the two groups were compared by means oft tests using
the summary data for the total mouth and for each of the six segments of the mouth.
The orthodontic group was subsequently divided on the basis of treatment time,
mechanics of treatment, and type of treatment (extraction or nonextraction). The peri-
odontal conditions were re-evaluated on the basis of these subdivisions. In addition, age
and plaque index were compared between the extraction and nonextraction groups in order
to assesstheir similarity between these two groups.
Findings
Matching of orthodontic and control groups. All subjects in both groups were Cauca-
sians. There was no statistically significant difference, according to &i-square analysis, in
the sex distribution between the orthodontic and control groups, with almost twice as
many females as males in both groups. There was no statistically significant difference in
age distribution between the two groups. The mean age for the orthodontic group was
38.66 years and for the control group, 37.72 years. Sixty-six percent of the subjects in the
orthodontic group had undergone orthodontic treatment more than 20 years previously.
Subjects from the two groups were from a similar and somewhat high socioeconomic
level. However, it was apparent that the parents of the control subjects had been of a
somewhat lower socioeconomic level many years previously.
The level of dental awareness, based on the regularity of dental visits, frequency of
toothbrushing, and the use of dental floss, was relatively high in both groups. Further-
more, there was no significant difference in the plaque index between the two groups,
considering the total mouth and each segment of the mouth (Table I). It was also apparent
that both groups demonstrated a relatively low mean plaque score, indicating a high level
of oral hygiene control.
Distribution of malocclusion. The type and distribution of malocclusion in both groups
were varied, with evidence of fairly marked malocclusions having been present in the
orthodontic group before treatment and also in the control group.
An over-all malocclusion index, whereby an index score was assigned to each variable
Table II. Gingival index in orthodontic and control groups

1 Mean 1 S.D. 1 Mean I s.D. I I valur

Total mouth 0.84 0.47 0.91 0.37 -1.23
Maxillary posterior right 0.86 0.51 O.Yh 0.40 -1.57
Maxillary anterior 0.63 0.50 0.70 0.46 - I .02
Maxillary posterior left 0.82 0.52 0.88 0.42 -0.92
Mandibular posterior left 0.89 0.46 1.01 0.39 -2.05*
Mandibular anterior 0.86 0.56 0.88 0.49 -0.22
Mandibular posterior right 0.98 0.48 I .05 0.38 -1.12

*Statistically significant (p < 0.05).

Table III. Pocket depth (in millimeters) in orthodontic and control groups
Orthodontic Control

Mean S.D. Mean S.D. t value

Total mouth 2.42 0.34 2.45 0.38 -0.47

Maxillary posterior right 2.63 0.44 2.66 0.45 -0.49
Maxillary anterior 2.14 0.34 2.22 0.43 -1.50
Maxillary posterior left 2.63 0.41 2.64 0.44 -0.22
Mandibular posterior left 2.15 0.39 2.66 0.41 1.67
Mandibular anterior 2.04 0.35 2.06 0.33 -0.41
Mandibular posterior right 2.73 0.49 2.12 0.48 0.26

describing the static occlusion, was developed. The average malocclusion index for the
orthodontic group prior to treatment was 8.15 (standard deviation, 3.20) and for the
control group, 7.72 (standard deviation, 2.74). The orthodontic group many years after
treatment showed some evidence of relapse as indicated by a mean malocclusion index of
2.84 (standard deviation, 2.74).
In the orthodontic group, 34.4 percent of the cases required 2 to 3 years of treatment,
18.8 percent required 3 to 4 years, and 12 ..5 percent required more than 4 years. Thirty-
eight percent of the patients had treatment involving the use of headgear; 13.5 percent of
these had a two-stage treatment approach which would account for the longer treatment
time. A nonextraction treatment approach was used in 61.5 percent of the cases, while
30.2 percent of the cases involved extraction of premolars in both arches. Prior to orth-
odontic treatment 34 percent of patients had Class I malocclusions and 66 percent had
Class II malocclusions. The Class I cases were almost equally divided between extraction
and nonextraction treatment approaches, while almost twice as many of the Class II cases
were treated on a nonextraction basis as on an extraction basis.
Periodontal condition. Considering the total mouth and each segment of the mouth,
the gingival index was significantly greater (P < 0.05) in the control group than in the
orthodontic group in the mandibular posterior left segment only (Table II). In general, the
mean gingival index was relatively low in both groups, indicating relatively good gingival
health with minimal inflammation.
There was no difference in mean pocket depth in millimeters as measured from the
 Orthodontic treatment and periodontal health 163

55 - Orthodontic
m- Control
45 -

40-

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l-
L 25-
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$2 2s
15 -

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0’ 1 I I I I I
TOTAL MAX. MAX. MAX. MAND. MAND. MAW.
MOUTH POST. ANT. POST. POST. ANT. POST.
RIGHT LEFT LEFT RltHT
MOUTH SEGMENTS

Fig. 1. Percentage of teeth in the mouth and each segment of the mouth with T.D.I. scores of 3 to 6 in
the orthodontic and control groups.

gingival margin between the two groups in the total mouth or in each segment of the
mouth (Table III). The mean pocket depth measurements were larger in the posterior
segments than in the anterior segments of the mouth. This measurement, as recorded
clinically, does not represent loss of attachment relative to the cementoenemal junction. A
more detailed and critical evaluation of the periodontal status was undertaken by means of
the tissue-destruction index (T.D.I.) score ranging from 1 to 6 as described by Geiger and
colleagues. 43 The T.D.I. score was derived from measurements of pocket depth, gingival
enlargement, and gingival recession relative to the cementoenamel junction for six sur-
faces of each tooth. The T.D.I. score for each tooth is a score of severity of periodontal
disease and represents “the calculated loss of periodontal support of the tooth modified by
the severity and the number of surfaces involved as interpreted by experienced clini-
cians.“43 T.D.I. scores of 3 to 6 are considered pathologic and indicative of periodontal
disease. Fig. 1 represents the mean percentage of teeth with T.D.I. scores of 3 to 6 in the
two groups, considering the total mouth and each segment of the mouth. There was no
statistically significant difference in the percentage of periodontally diseased teeth be-
tween the two groups, although the values tended to be consistently greater in all regions
of the mouth in the orthodontic group. The increase was greater in the posterior segments
of the mouth, with the mandibular arch affected more than the maxillary arch.
When separate T.D.I. scores of 1 to 6 were evaluated, the orthodontic group exhibited
a greater percentage of teeth with T.D.I. scores of 3 (indicative of mild to moderate
periodontal disease) than the control group, considering the total mouth, both maxillary
posterior segments and the mandibular anterior segment (Table IV). There was a very
small percentage of teeth in the mouths of both groups of subjects with T.D.I. scores of 4
to 6 (indicative of more severe periodontal disease) (Table V).
From the questionnaire, it was ascertained that 17 percent of the subjects in the
Table IV. Percentage of teeth with T.D.I. scores of 3 in orthodonttc and control groups
-
Orthodontic Control

Mean S.D. Mean S.D. t value

Total mouth 29.71 21.45 22.48 18.41 2.z%*

Maxillary posterior 42.19 33.36 30.19 35.36 2.46*
Maxillary anterior 12.38 21.62 1.67 17.39 1.70
Maxillary posterior left 37.03 34.69 26.59 30.65 2.25%
Mandibular posterior left 46.46 37.02 36.68 33.67 I .95
Mandibular anterior 11.75 24.00 5.83 IS.61 2.05*
Mandibular posterior right 51.42 33.89 43.40 35.01 1.64

*Statistically significant (p < 0.05).

Table V. Mean percentage of teeth with T.D.I. scores of 4, 5, and 6 in orthodontic and
control groups

Orthodontic Control

Total mouth 2.46 4.17

Maxillary posterior 3.82 5.12
Maxillary anterior 0.87 4.21
Maxillary posterior left 4.43 6.01
Mandibular posterior left 1.91 2.31
Mandibular anterior 1.74 2.16
Mandibular posterior right 3.20 5.25

orthodontic group reported having had periodontic treatment as compared with 9 percent
of the subjects in the control group.
A question arises concerning the difference in the nuraber of teeth lost for possible
periodontal reasons in the two groups. There were almost twice as many teeth missing in
the orthodontic group than in the control group, except for third molars and excluding
teeth that had been extracted as part of orthodontic treatment. However, when questioned
as to the reasons for the extractions, only three subjects in the orthodontic group and one
in the control group gave “loose teeth” as a reason.
In order to evaluate the periodontal condition in the orthodontic group further, three
separate sets of subgroupings were created with respect to the orthodontic treatment
experience:
1. The group whose orthodontic treatment time was up to 24 months was compared to
the group whose treatment time extended beyond 24 months. All aspects of the periodon-
tal condition in each separate region of the mouth were compared by means of Student’s t
tests. Statistically significant differences were apparent in very few variables in certain
areas of the mouth (Table VI). The percentage of teeth in the total mouth with T.D.I.
scores of 4 (indicating more severe periodontal disease) was 0.68 percent in the group
treated within 24 months as compared to 2.05 percent in the group with a longer treatment
time. Similarly, the percentage of teeth with gingival recession scores of 2 was smaller in
the maxillary anterior segment in the group with a shorter treatment time. Also, the
percentage of teeth with gingival recession scores of 3 was smaller in the maxillary right
posterior segment in the group with a lesser treatment time.
Volume 80
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Orthodontic treatment and periodontal health 165

Table VI. Periodontal condition in the orthodontic group related to treatment time
Treatment time

~24 months >24 months

(N = 32) (N =64)

Variable Segment Mean S.D. Mean S.D. t value

Percent of teeth with T.D.I. of 4 Total mouth 0.68 1.93 2.05 4.43 -2.10*
Percent of teeth with gingival en- Total mouth 2.50 3.91 1.35 1.77 2.cQ*
largement of 3 Mandibular posterior left 6.14 6.40 3.31 5.31 2.29*
Percent of teeth with gingival reces- Total mouth 90.56 8.73 85.38 14.71 2.16*
sion of 1 Maxillary posterior right 91.74 7.61 84.21 17.16 2.98**
Percent of teeth with gingival reces- Maxillary anterior 4.10 5.77 7.55 9.56 -2.20*
sion of 2
Percent of teeth with gingival reces- Maxillary posterior right 0.26 1.03 2.02 5.70 -2.39*
sion of 3
*Statistically significant (p < 0.05).
**Statistically significant (p < 0.01).

2. With respect to treatment mechanics, two groups were selected according to the
use of maxillary headgear, with the realization that this would also, to some extent, reflect
the severity of the malocclusion, thereby possibly requiring a lengthier treatment time.
There were no significant differences between these two groups.
3. Finally, two groups were created, depending on whether extractions had been per-
formed in both arches as part of the orthodontic therapy or whether the malocclusion had
been resolved without extractions. The variables considering different regions of the mouth
that were significantly different between the two groups are shown in Table VII. In the
extraction group there was a significantly greater percentage of teeth with T.D.I. scores of
3 to 6 (indicating periodontal disease) in the maxillary right posterior segments and in the
mandibular posterior segments. Similarly, the percentage of teeth with T.D.I. scores of 3
(moderate periodontal disease) was greater in the mandibular posterior segments in the
extraction group. Also, pocket depth (as measured from the gingival margin) was greater
in the mandibular right posterior segments in the extraction group. The latter finding may
have been due to the fact that the gingival enlargement score of 2 in the mandibular right
posterior segment was also greater in the extraction group. Since significant differences in
the periodontal condition were apparent between the extraction and nonextraction sub-
groups, the two subgroups were tested for differences in age and plaque index by means of
t tests. There were no significant differences in age or plaque index (considering the whole
mouth and each segment of the mouth) between the extraction and nonextraction sub-
groups; thus, these two important variables were eliminated as possible contributing
factors in the periodontal condition.
The number of recordings in the total mouth and in each segment of the mouth which
exhibited attached gingiva minus pocket depth differences equal to or less than 1 mm. was
computed from the clinical recordings of attached gingiva, as measured from the gingival
margin at three points on the facial aspects of each tooth, and the corresponding mea-
surements of pocket depth, as measured clinically from the gingival margin. This com-
puter value was considered as being evidence of a mucogingival problem. The only
Table VII. Periodontal condition in the orthodontic group related IO treatment type
7watment type

Extraction
Max i
Nonextruction Mand.
(N = 59) (N = 29)

Variable Segment Mean S.D. Mean S.D. t value

Percent of teeth with T.D.I. of 3-6 Maxillary posterior right 41.24 34.67 58.05 37.23 -2.09*
Mandibularposteriorleft 42.40 35.33 61.78 40.12 -2.31*
Mandibular posterior 49.49 36.46 66.04 29.34 -2.13*
right
Percent of teeth with T.D.I. of 2 Mandibular posterior left 56.75 34.89 37.07 40.74 2.35*

Mandibular posterior 50.08 36.61 31.95 30.60 2.30'

right
Percent of teeth with T.D.I. of 3 Mandibular posterior left 40.71 33.65 59.77 38.84 -2.37*
Mandibular posterior 45.85 34.66 63.74 27.86 -2.42*
right
Pocket depth (mm.) Mandibular posterior 2.64 0.48 2.88 0.40 -2.33*
right
Percent of teeth with gingival enlarge- Mandibular posterior 66.14 20.62 55.44 23.71 2.18*
ment of 1 right
Percent of teeth with gingival enlarge- Mandibular posterior 30.43 18.55 39.91 22.63 -2.09*
ment of 2 right

*Statistically significant (p < 0.05).

statistically significant difference (P CO.01) between the two groups was apparent in the
mandibular posterior right segment of the mouth, where the control group exhibited a
greater number of areas with such mucogingival problems (Table VIII). In the total mouth
there was an average of 13.71 such areas in the orthodontic group and 16.05 in the control
group, although the difference was not statistically significant. More areas with mucogin-
gival problems occurred in the mandibular arch than in the maxillary arch, with mandibu-
lar posterior segments most affected. In addition, no difference existed in the number of
areas with mucogingival problems in orthodontic subjects treated with an extraction as
compared to a nonextraction approach.
Discussion
It was apparent from the findings of this study that the orthodontically treated and
control groups were similar with regard to race, sex, age, and plaque index, a measure of
oral hygiene control. The over-all dental awareness score (derived from regularity of
dental visits, toothbrushing, and use of dental floss) was also similar for the two groups,
although the control group showed greater regularity of dental visits and greater use of
dental floss. Both groups were from a rather high socioeconomic level with minor differ-
ences in occupational categories. Also, the level of dental awareness and oral hygiene was
particularly high in both groups. It should be realized that an effort was made to identify
control subjects from a high socioeconomic level since it was apparent, after examination
Volume 80
Number 2 Orthodontic treatment and periodontal health 167

Table VIII. Number of areas with mucogingival problems in orthodontic and

control groups
I Orthodontic II Control I

Mean S.D. Mean S.D. t value

Total mouth 13.71 6.94 16.05 10.52 -1.86

Maxillary posterior right 1.16 1.37 1.50 2.09 -1.40
Maxillary anterior 0.61 1.12 0.55 1.42 0.34
Maxillary posterior left 1.46 1.62 1.41 1.86 0.20
Mandibular posterior left 4.42 2.42 5.06 3.50 -1.51
Mandibular anterior 2.92 2.85 3.67 3.39 -1.69
Mandibular posterior right 3.15 1.68 3.85 2.14 -2.59*

*Statistically significant (p < 0.01).

of a large number of the orthodontic subjects, that they were of a high socioeconomic
level. Some indirect evidence does exist, however, to suggest that the socioeconomic
level and dental awareness level in the control group may have been lower many years
previously. The parents of the control subjects were of a lower socioeconomic level and
the control subjects had lost a greater number of teeth through extraction as a consequence
of decay. The possibly lower socioeconomic level in the control group many years
previously may also account for the fact that the control subjects did not have orthodontic
therapy for the correction of their malocclusions.
In the design of this study it was planned to have a control group that exhibited a
plaque index that was similar to that in the orthodontic group. This was achieved by
selecting control subjects with a high level of dental awareness as determined by the
questionnaire.
The average age of both groups was beyond 35 years, with approximately 66 percent
of the orthodontic group being more than 20 years postorthodontic treatment. This is
particularly important, since periodontal disease is more prevalent in the general popula-
tion with advancing age.57
The two groups were therefore similar with regard to many of the factors that would
influence the development of periodontal disease, except that the orthodontic group had
received comprehensive fixed-appliance orthodontic treatment for correction of their
malocclusion, whereas the control group exhibited malocclusions that had not been treated
orthodontically.
The malocclusions in the orthodontic group prior to treatment and in the control group
consisted of Class I and Class II malocclusions, with evidence of a wide range of severity.
There were, however, few cases of true open-bite, anterior cross-bite, or posterior cross-
bite. It was also apparent that the orthodontic group, being many years out of retention,
showed evidence of relapse to a varying degree and, these subjects therefore, cannot be
considered as having ideal occlusions. The orthodontic therapy in the orthodontically
treated group involved the extraction of teeth in 30.2 percent of patients, and all of the
patients were treated with full banded edgewise appliances. In 31 percent treatment took
more than 3 years, which may be considered relatively long. However, there were twice
as many Class II as Class I cases, which may account for the longer treatment time.
 The findings indicated that the gingival health in both groups was similar and, on the
average, very good, which is what might be expected since both groups had a generally
high level of dental awareness and oral hygiene.
Average pocket depth, measured to the gingival margin, was relatively low and similar
in both groups. There was also no statistically significant difference in periodontal dis-
ease, as evaluated by the tissue-destruction index (T.D.I.)4” between the orthodontically
treated and control groups, considering the total mouth and each segment of the mouth.
The T.D.I. score represents “the calculated loss of periodontal support of the tooth
modified by the severity and number of surfaces involved, as interpreted by experienced
clinicians. ‘x1.7Use of the index avoided the problem of using average measurements of
loss of periodontal support, which tends to mask the location and degree of pathosis present.
Considering separate T.D.I. scores of 1 to 6, the only statistically significant difference
between the two groups was that the orthodontic group had a greater percentage of teeth
with T.D.I. scores of 3 in the maxillary posterior and mandibular anterior segments,
indicating mild to moderate periodontal disease. These differences probably cannot be
accounted for by factors related to traumatic occlusion, since no differences were found in
the prevalence of nonfunctional occlusal contacts between the two groups..‘X More detailed
investigation of these areas is warranted. There was, however, a very small and similar
percentage of teeth with more severe periodontal disease in both groups, which again is
probably related to the high level of oral hygiene.
A possible influence on the periodontal findings could have been tooth loss. In fact,
the control group had more teeth missing than the orthodontic group, excluding third
molars and teeth extracted as part of the orthodontic treatment. However, when ques-
tioned as to the reasons for the extractions, only three of the subjects in the orthodontic
group and one in the control group gave “loose teeth” as a reason, which suggests that
advanced periodontal disease did not account for differences between the two groups in
the number of teeth missing. Seventeen percent of the orthodontic group reported having
had periodontal therapy, as compared to 9 percent in the control group. It is, however,
difficult to evaluate the effect of peridontal therapy on the periodontal findings between
the two groups.
Some evidence existed to suggest that in the former orthodontic patients who had teeth
extracted as part of their orthodontic therapy there was a greater prevalence of mild to
moderate periodontal disease in the posterior regions of the mouth as compared to patients
who were treated without extraction. These differences were not due to differences in age
or plaque control between the two groups.
Minor differences were apparent between those subjects in the orthodontic group
whose treatment time was less than 24 months and those with a longer treatment time.
Also, we found no apparent differences in those orthodontic patients whose treatment
involved the use of maxillary extraoral headgear, realizing that headgear would to some
extent reflect the severity of malocclusion, thereby also possibly requiring a longer treat-
ment time.
Mucogingival problems occurred with similar frequency in the two groups. Also,
there were no apparent differences in the incidence of mucogingival problems between
those orthodontic patients treated with extractions and those treated with a nonextraction
basis.
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Orthodontic treatment and periodontal health 169
Number 2

It therefore appears that there is no greater prevalence of peridontal disease in a group

of adults with untreated malocclusions than in a similar group of adults whose malocclu-
sions were treated orthodontically during adolescence many years previously. In spite of
having had extensive orthodontic treatment, the orthodontic group as a whole did not
show evidence of severe periodontal disease many years later. However, orthodontists
must monitor oral hygiene very carefully during orthodontic treatment because, on an
individual basis, more severe gingival and periodontal problems may occur in some
instances and it is important to keep these as minimal as possible. Also, none of the
subjects used in this study were treated during adulthood, when there might be a possibly
greater risk of periodontal breakdown during orthodontic treatment.
It is obvious that this study could not evaluate the often stated contention that because
of the more ideal tooth positions after orthodontic treatment, plaque retention would not
occur as readily and oral hygiene would be easier to control, thereby lessening the
potential for development of periodontal disease. In order to answer the questions posed in
this study, control subjects with a high level of dental awareness were identified so that the
control group would be as similar as possible to the orthodontic group except for the
presence of untreated malocclusions. Any possible psychosocial benefits of orthodontic
treatment or possible improvement in dental awareness and improved oral hygiene in
postorthodontic patients could also not be evaluated.
Summary and conclusions
The objective of this study was to evaluate the periodontal health of a group of patients
who had received comprehensive fixed-appliance orthodontic treatment during adoles-
cence between 12 and 35 years previously. The periodontal health of this group was
compared with that of a group of subjects who were similar with regard to race, sex, age,
socioeconomic status, dental awareness, and oral hygiene status but had malocclusions
that had not been orthodontically treated.
The findings indicated that there were no statistically significant differences in the
general prevalence of periodontal disease between the two groups. However, more de-
tailed statistical analysis revealed the following exceptions:
1. While no differences were observed in the prevalence of moderate to severe peri-
odontal disease (T.D.I. scores of 4 to 6), the orthodontic group manifested a greater
prevalence (P < 0.05) of mild to moderate periodontal disease (T.D.I. score of 3) than
the control group in the maxillary posterior and mandibular anterior regions of the mouth.
2. A greater prevalence of mild to moderate periodontal disease was found in the
posterior regions of the mouth in those orthodontic patients whose treatment included
extractions than in those treated without extractions.
Except for these differences, there were no other major periodontal problems that
could be related to the effects of orthodontic treatment. Mucogingival problems were
found with similar frequency in the orthodontically treated and control subjects and no
differences in this regard were observed between orthodontic patients whose treatment
involved extractions and those treated without extractions.
Since control subjects were selected with a high level of dental awareness similar to
that of the orthodontic group, these results suggest that orthodontic therapy in adolescence
is not a major factor in determining the long-term periodontal health status. Therefore, no
170 SudowskJ and BeCole

significant amount of either damage or benefit to the periodontal structures can be attrib-
uted directly to orthodontic therapy. Conversely, the lack of orthodontic therapy in
adolescence does not appear to influence subsequent development or nondevelopment of
periodontal disease in adults.
We would like to thank Dr. Raymond L. Wright and Dr. Stanley Treitler for performing the
clinical examinations, Dr. Elliot 1. Sakols and Dr. Gregory Jackson for assisting with the orthodon-
tic records, Ms. Roseanne Williamson (C.D.A.) for patient scheduling and chairside assistance, and
Ms. Harriet Gorny for computer programming. Computing services were provided by the Computer
Center, University of Illinois, Chicago Circle Campus, Chicago, Illinois.

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