Accepted: 29 October 2017

DOI: 10.1111/jcpe.12835

RANDOMIZED CLINICAL TRIAL

Orthodontic treatment simultaneous to or after periodontal

cause-­related treatment in periodontitis susceptible patients.
Part I: Clinical outcome. A randomized clinical trial

Eglė Zasčiurinskienė1,2  | Nomeda Basevičienė3 | Rune Lindsten2,4 | 

Christer Slotte5,6,* | Henrik Jansson2,5 | Krister Bjerklin4

1
Department of Orthodontics, Medical
Academy, Lithuanian University of Health Abstract
Sciences, Kaunas, Lithuania Aim: To compare two treatment strategies regarding the effect of orthodontic treat-
2
Centre For Oral Health, School of Health and
ment on periodontal status in patients with plaque-­induced periodontitis.
Welfare, Jönköping University, Jönköping,
Sweden Subjects and Methods: This was a randomized clinical trial. Fifty periodontal patients
3
Department of Dental and Oral were randomly assigned to the test or control groups according to periodontal treat-
Pathology, Medical Academy, Lithuanian
ment timing. All patients received supra-­and subgingival debridement following base-
University of Health Sciences, Kaunas,
Lithuania line examination. Control group patients received cause-­related periodontal treatment
4
Department of Orthodontics, Institute for before the start of orthodontic treatment and which was performed simultaneous to
Postgraduate Dental Education, Jönköping,
Sweden orthodontic treatment for the test group patients.
5
Department of Periodontology, Institute for Results: No difference between the test and control groups was found regarding
Postgraduate Dental Education, Jönköping, change of clinical attachment level (CAL) after periodontal–orthodontic treatment.
Sweden
6 Fewer sites with initial pocket depth (PD) of 4–6 mm healed after periodontal–ortho-
Department of Biomaterials, Institute
for Clinical Sciences, Sahlgrenska dontic treatment in the test group (20.5%, IQR = 11.9%) in comparison with controls
Academy, University of Gothenburg,
(30.4%, IQR = 27.1%) (p = .03). Anterior teeth [OR 2.5] and teeth in male patients [OR
Göteborg, Sweden
1.6] had a greater chance for PD improvement ≥2 mm. Total periodontal–orthodontic
Correspondence
treatment duration was significantly longer for the control group (p < .01).
Eglė Zasčiurinskienė, Department of
Orthodontics, Lithuanian University of Health Conclusions: Both groups showed a gain of CAL and a reduction in sites with PD ≥
Sciences, Kaunas, Lithuania.
4 mm. Orthodontic treatment, simultaneously to the periodontal treatment, could be
Email: eglezas@gmail.com
used in the routine treatment of patients with plaque-­induced periodontitis.

KEYWORDS
clinical attachment level, gingival recession, orthodontic treatment, periodontal treatment,
periodontitis, pocket depth

1 | INTRODUCTION successfully performed (Badersten, Nilveus, & Egelberg, 1981, 1984;

Periodontitis is described as a result of an imbalance of the oral mi-
crobiota, in the dento-­gingival area, and the host response leading
to inflammation and destruction of the periodontium in susceptible
individuals (Berglundh & Donati, 2005; Flemmig, 1999). To reduce
microorganisms, both non-­surgical and surgical therapies have been
Becker et al., 2001; Deas, Moritz, Sagun, Gruwell, & Powell, 2016;
Isidor & Karring, 1986; Kaldahl, Kalkwarf, Patil, Dyer, & Bates, 1988;
Ramfjord et al., 1987; Sanz, Alonso, Carasol, Herrera, & Sanz, 2012).
As a consequence of plaque-­
induced periodontitis, patients
with increased numbers of teeth showing attachment loss also have

*Deceased February, 2016.

J Clin Periodontol. 2018;45:213–224. wileyonlinelibrary.com/journal/jcpe   © 2017 John Wiley & Sons A/S. |  213
Published by John Wiley & Sons Ltd
214      | ZASČIURINSKIENĖ et al.

pathological migration of anterior teeth, decreased posterior bite

height and worsened smile aesthetics (Brunsvold, 2005; Johal & Ide,
Clinical Relevance
1999). The latter is the most common reason for patients seeking
Scientific rationale for the study: Two treatment strategies
treatment.
regarding the effect of orthodontic tooth movement on
Some clinical studies have shown that orthodontic treatment
periodontal status in patients with plaque-­induced perio-
may be effective in intruding and replacing the migrated max-
dontitis were tested in this trial.
illary incisors (Artun & Urbye, 1988; Cardaropoli, Re, Corrente,
Principal findings: Combined periodontal–orthodontic treat-
& Abundo, 2001, 2004; Corrente, Abundo, Re, Cardaropoli, &
ment resulted in about 1/4 of sites with CAL gain despite
Cardaropoli, 2003; Melsen, 2001). The use of orthodontic tooth
the periodontal treatment timing. Significantly more sites
movement after conventional periodontal therapy in periodontally
with initial PD 4–6 mm healed where periodontal treatment
involved patients has been described in a number of case reports in
was performed before orthodontic treatment.
the past years (Agarwal et al., 2014; Fukunaga, Kuroda, Kurosaka,
Practical implications: Combined periodontal–orthodontic
& Takano-­Yamamoto, 2006; Janson, Janson, & Murillo-­Goizueta,
treatment showed a gain of CAL and a reduction in sites
2011; Nakamura, Gomi, Oikawa, Tokiwa, & Sekiya, 2013; Pinho,
with PD 4 
mm. Simultaneous periodontal–orthodontic
Neves, & Alves, 2012). However, the effect of orthodontic treat-
treatment could be used in the routine treatment of patients
ment on periodontal tissues, the risks and benefits of orthodontic
with plaque-­induced periodontitis.
tooth movement in the patients with periodontal pathology is con-
troversial and lacking sufficient scientific evidence (Zasciurinskiene,
Lindsten, Slotte, & Bjerklin, 2016). Therefore, it is not clear if it
2 | MATERIALS AND METHODS
could be used as a routine treatment protocol in periodontally in-
volved dentitions.
2.1 | Subjects
Tooth movement in reduced, but healthy periodontium may
improve attachment level, and conversely, in active periodontal This trial was performed according to the Declaration of Helsinki
cases, orthodontic treatment may cause further progression of guidelines. Approval by the Regional Ethical Review Board in Kaunas,
periodontal destruction (Ericsson, Thilander, Lindhe, & Okamoto, Lithuania, and informed consent from the patients were obtained. All
1977; Melsen, 2001; Melsen, Agerbaek, Eriksen, & Terp, 1988 patients were given oral and written information about the study de-
Wennstrom, Lindhe, Sinclair, & Thilander, 1987). These studies led sign and their right to withdraw from the study at any time without
to the knowledge that periodontal treatment should be performed negative effect on their future treatment.
first.
The aim of the present randomized clinical trial was to compare
2.1.1 | Selection criteria
two treatment strategies regarding the effect of orthodontic tooth
movement on periodontal status in patients with plaque-­induced peri- The selection period lasted from 2010 to 2015. Occlusion, function
odontitis. The secondary aim was to evaluate differences in treatment and aesthetics were evaluated for all individuals with plaque-­induced
duration. periodontitis, who were consecutively attending the Department of
The null hypothesis tested was that no statistically significant dif- Dental and Oral Pathology, Lithuanian University of Health Sciences
ference could be demonstrated between the test and control groups (LUHS) and two private clinics in Kaunas, Lithuania. Patients having
assessing clinical attachment level (CAL) change after combined peri- malocclusion were consulted by orthodontist (EZ) and selected for the
odontal–orthodontic treatment. trial according to inclusion and exclusion criteria (Table 1).

T A B L E   1   Inclusion and exclusion criteria

Inclusion criteria Exclusion criteria

• >25 years of age; • any systemic disease (e.g. diabetes) or medication that would
• good general health status; influence treatment;
• a minimum of six anterior teeth present; • periodontal treatment in the previous 2 years;
• periodontitis experience and marginal bone loss at ≥3 teeth and more • pregnant or lactating women;
than 1/3 of the root length (assessed by panoramic radiographs); • smokers (>5 cigarettes/day);
• ≥3 teeth with bleeding on probing (BoP), pocket depth (PD) ≥4 mm • failure to comply to oral hygiene instructions provided or/and to keep
and loss of clinical attachment level (CAL) ≥4 mm (assessed by clinical to regular study appointments.
examination);
• malocclusion that needs orthodontic treatment.
ZASČIURINSKIENĖ et al.
2.2 | Trial design
This was a randomized, controlled, parallel, open-­label clinical trial.
The CONSORT (consolidated standards of reporting trials) guidelines
for clinical trials were followed (Moher et al., 2012; Pandis, 2013).
2.2.1 | Randomization and allocation concealment
After consultation by orthodontist, selected patients were offered the
treatment with fixed orthodontic appliances. The patients who con-
sented to undergo orthodontic treatment were randomly assigned
into either the intervention test group (periodontal treatment simul-
taneous to orthodontic treatment) or the control group (periodontal
treatment before orthodontic treatment) (Figure 1). Randomization
was performed immediately after baseline examination according to
a computer-­generated randomization list. All patients were numbered
F I G U R E   1   Flow chart of trial patients
|
      215
consecutively. Clinicians and patients were not blinded due to the de-
sign of this research. Patients who dropped out of the study (n = 2)
were replaced by additional patients, but no later than January 2015
(Figure 1).
All trial patients received oral hygiene instructions (OHI) and pro-
fessional oral hygiene (POH) (Figure 2).
Test group: Twenty-­five patients started orthodontic treatment
with conventional straight-­wire mechanics directly after POH. Non-­
surgical therapy and subsequent periodontal surgery in sites showing
probing depth (PD) ≥6 mm that bled on probing were performed after
orthodontic alignment and levelling phases had been finished.
Control group: Twenty-­five patients received cause-­related non-­
surgical therapy with subsequent periodontal surgery in sites show-
ing PD ≥6 mm that bled on probing, before orthodontic treatment.
Orthodontic treatment was applied as in the test group (Figure 2).
Changes in periodontal status were compared between the groups.
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216       ZASČIURINSKIENĖ et al.

F I G U R E   2   Flow chart of trial procedures

examination. The result was assessed after 2 weeks. In cases with BoP
2.3 | Periodontal treatment (PT)
> 30%, POH was repeated.

2.3.1 | Professional oral hygiene

2.3.2 | Cause-­related periodontal treatment
POH treatment including the removal of supra-­and subgingival cal-
culus by ultrasonic instrumentation supplemented with hand instru- Non-­surgical therapy was performed under local anaesthesia at dif-
ments was performed for every study patient following baseline ferent time points (Figure 2). Treatment was scheduled in four weekly
ZASČIURINSKIENĖ et al.
visits. Patients had to rinse with a 0.12% chlorhexidine solution twice
daily during this phase.
2.3.3 | Periodontal surgery
Modified Widman flap surgery was scheduled and performed in
sites showing PD ≥6 mm that bled on probing, following SRP at the
3-­month follow-­up visit. All patients were prescribed mouth rinsing
with a 0.12% chlorhexidine solution twice daily during the surgical
phase and for two weeks following surgery (American Academy of
Periodontology 2011). No antibiotics were prescribed for the ad-
ditional effect of periodontal treatment. However, antibiotics in
Lithuania are easily accessible and often used to treat other diseases
as in many parts of the world.
The application of active orthodontic forces for the test group was
postponed 2–4 weeks after periodontal surgery.
2.3.4 | Supportive periodontal treatment
OHI (including interproximal brushing) was performed continuously
throughout all treatments for both groups (Figure 2). POH was con-
tinuously maintained at 3–6 month intervals by a dental hygienist dur-
ing OT.
2.4 | Orthodontic treatment (OT)
Orthodontic treatment with straight-­wire appliance was performed in
the Orthodontic Department of LUHS and two private clinics by one
of the authors (EZ).
Good oral hygiene with a full-­mouth plaque score <25% was as-
sured before the start of OT (Lang & Tonetti, 2003).
After baseline examination and POH, the decision was made about
the teeth that needed to be moved in each patient. This depended
on the number of teeth present, the severity of malocclusion of each
patient, planned/existing neighbouring implants and/or prosthetic
restorations.
Self-­
ligating brackets with MBT (McLaughlin, Bennett, Trevisi),
prescription (3M Unitek Orthodontic Products; Monrovia, CA, USA)
and 0.022-­inch slot were used. Aesthetic brackets (Clarity™ SL) were
used for maxillary anterior segment to fulfil the aesthetic requirements
of the trial patients according to individual needs. Initial levelling and
alignment were performed using round, nitinol heat-­activated arch-
wires (3M Unitek Orthodontic Products; Monrovia, CA, USA). The
inter-­dental enamel reduction technique was used in crowded cases
where needed. Intrusion and retrusion of maxillary and/or mandibular
anterior teeth were provided in flared incisor cases. Space closure was
performed using rectangular or round stainless steel wires. Anchorage,
where needed, was ensured with microscrews or temporary crowns
on implants.
Following active OT, the fixed appliances were removed and a
fixed (multistrand wire) orthodontic retainer for maxillary and man-
dibular anterior teeth was applied for all patients and Hawley or
|
      217
vacuum-­pressured retainers were provided for the night time for un-
limited period of time.
2.5 | Clinical examination
Standardized clinical measurements at all time points for every trial
patient were performed by the same investigator (EZ). Measurements
were recorded on forms designed for the trial. The measurements
were performed at all sites around each tooth with a manual peri-
odontal probe (Hu-­Friedy PCP-­UNC 15, Chicago, IL, USA). Only the
deepest measurement was recorded for each of the four sites: mesial
(M), buccal (B), distal (D) and lingual (L). To decrease measurement bias
of the clinical parameters, every clinical examination was recorded on
a separate record form at every time point. Periodontal assessments
before and after OT were performed only for teeth that were ortho-
dontically moved.
T0: Baseline examination. All participants were given a baseline ex-
amination including the following measurements:
• Visible plaque index (VPI): counted by the presence of visible dental
plaque along the gingival margin at four sites (M-B-D-L) of each
tooth and expressed as a percentage of examined sites within each
subject (Ainamo & Bay, 1975).
• Bleeding on probing (BoP): measured after probing to the base of
the pocket.
• Pocket depth (PD): measured from the gingival margin to the bot-
tom of the pocket at four sites (M-B-D-L) and recorded to the near-
est millimetre.
• Gingival recession (REC): measured as a distance from the cemen-
to-enamel junction (CEJ) to the gingival margin at four sites (M-B-
D-L) and recorded to the nearest millimetre.
• Clinical attachment level (CAL): measured as a distance from the
bottom of the pocket to cement–enamel junction and recorded in
millimetres at four sites (M-B-D-L).
T1: Pre-orthodontic examination. All patients were examined before
OT start with all and the same measurements: VPI, BoP, PD, REC and
CAL.
T2: Post-orthodontic examination (study end point). All patients were
examined the day of bracket debond: VPI, BoP, PD, REC and CAL.
Changes in periodontal status were compared between time
points T0, T1, T2 in both groups.
2.5.1 | Examination during OT
Every 3 to 6 months: BoP, PD.
2.6 | Radiographic examination
The enrolled study patients were examined with panoramic radio-
graphs before PT for diagnostic purpose—evaluation of alveolar bone
status.
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218       ZASČIURINSKIENĖ et al.
2.7 | Outcomes
Gain in CAL was chosen as the primary response variable to judge
the effectiveness of the treatment (Page & DeRouen, 1992; Savage,
Eaton, Moles, & Needleman, 2009). Secondary outcomes included (i)
PD reduction; (ii) REC development, (iii) treatment duration.
2.7.1 | Data management
Data analyses were based on the patient as the unit of measure. CAL
gain was evaluated by the millimetre change. Measurement analysis
included sites that had CAL ≥4 mm and expressed as median value
of the assessed registrations within each subject in test and control
groups at time points corresponding to T0 and T2.
CAL and PD changes in patient level were also evaluated in the
subgroup analysis. Sites were classified as follows: <4 mm, 4–6 mm
and >6 mm. Sites that had changed CAL and PD class during treatment
phases T0–T1, T1–T2 and T0–T2 were analysed.
Analysis was performed also at tooth level for PD change from T0
to T2. Only sites PD ≥4 mm were included. PD change was measured
for every tooth number according to FDI World Dental Federation
system. PD change T0–T2 was grouped (<2 and ≥2 mm) according to
median value of 2 mm. Teeth were also grouped as anterior (central
incisors, lateral incisors, canines) and posterior (premolars, molars).
Two age groups (≤35 and >35 years) were also created (Demmer &
Papapanou, 2010). PD change of ≥2 mm as dependent variable was
used in multivariate binary logistic regression analysis model.
2.8 | Statistical analysis
2.8.1 | Sample size
The CAL difference of 1.0 mm was considered to be of clinical impor-
tance between the test and control groups. To be able to detect a clin-
ically meaningful difference in mean CAL of 1.0 mm between groups,
standard deviation of 1.0 mm, with a power of 90% and an alpha-­level
at 0.05, 22 patients were needed in each group. To compensate for
dropouts, twenty-­five patients were recruited in each group.
2.8.2 | Statistical method
Statistical data analysis was performed using SPSS 20.0 program
package (SPSS Inc, Chicago, IL).
Every data set was tested for normality by Shapiro–Wilk test.
Statistical analyses to compare two independent variables were con-
ducted using Student’s t test or Mann–Whitney U test.
Wilcoxon signed-­ranks test was used for dependent variables.
A chi-­square test was used to compare the proportions of categor-
ical variables between the groups.
To determine correlation between variables, Spearman’s coeffi-
cient was used.
Logistic regression analysis was performed to determine odds ratio
(OR) predictive values.
For the assessment of reproducibility of measurements made by
two investigators, the interclass correlation coefficient (ICC) and “con-
sistency type” were used. Intra-­class reproducibility (EZ) was calcu-
lated with “absolute agreement” type.
In all analyses, a p value <.05 was considered significant.
2.8.3 | Calibration
Calibration of the investigator (EZ) was performed twice (with 1-­year
interval) during the experimental period by recording measurements
of same half mouth of each of three patients by periodontologist (NB)
and orthodontist (EZ). Examiners were blinded to each other. CAL at
four sites of 30 teeth was examined. A total of 120 repeated measure-
ments were evaluated.
The repeated measurements were made twice at the same visit
with 30-­min intervals for intra-­class reproducibility for the author EZ.
The analysis showed high interclass agreement (0.95; 95% CI:
0.92, 0.96; p = .0001) and intra-­class agreement (0.93; 95% CI: 0.87,
0.95; p = .0001).
3 | RESULTS
3.1 | Participant flow
The present trial was conducted between 2010 and 2016.
The flow chart of trial patients and the reasons for exclusion are
presented in Figure 1.
In total 50 selected patients, 25 in the test and 25 in the control group
started periodontal–orthodontic treatment. After two withdrawn and
two replaced patients, 50 patients completed the trial and were finally
evaluated. Reasons for dropout are shown in the flow diagram (Figure 1).
3.2 | Baseline data
The baseline demographic and clinical data for both groups are
shown in Table 2. There were no significant differences between
the test and control treatment groups. One patient in each group
smoked ≤5 cigarettes per day. Both of them stopped smoking during
the treatment.
Majority of included patients showed reduced posterior height of
the occlusion with proclined anterior teeth (80%). Most of them had
spacing in the upper and/or lower teeth and/or over-­eruption of inci-
sors. Nineteen (38%) patients had flared maxillary incisors. Dental mal-
occlusions according to angle classification are described in Table 2.
3.3 | Adverse events
One maxillary central incisor developed severe apical root resorption
more than 1/3 of the root. Due to reduced bone level and extensive
apical root resorption, this tooth was deemed for extraction after OT.
One maxillary central incisor developed severe external root re-
sorption with extension to the pulp. This tooth was vital, resulted in
CAL gain with PD <4 mm and was left for follow-­up.
ZASČIURINSKIENĖ et al. |
      219

T A B L E   2   Comparison of baseline parameters between test and T A B L E   2   (Continued)

control group patients included in the trial
Variable Test n = 25 Control n = 25 p value

Variable Test n = 25 Control n = 25 p value % teeth BoP

Teeth for ortho tx (n) 479 520 .8 Median (IQR) 95.7 (78.9, 100) 100 (77.5, 100) .4

Maxillary incisors (n) 90 95 CAL, clinical attachment level; PD, probing depth; REC, gingival recession;
Maxillary canines (n) 45 48 BoP, bleeding on probing; IQR, interquartile range; ortho tx ,orthodontic
treatment.
Maxillary premolars (n) 59 66

Maxillary molars (n) 41 48

Mandibular incisors (n) 87 94 3.3.1 | CAL change after periodontal–orthodontic

Mandibular canines (n) 46 48 treatment (T0–T2)
Mandibular premolars (n) 72 83 No difference in CAL change was found between test and control pa-
Mandibular molars (n) 39 38 tients. Twenty-­two (88%) patients in every group resulted in CAL gain.
n teeth with PD≥ 4 mm The values are presented in Table 3.
Mean (SD) 13.2 (5.70) 15.8 (5.96) .1

Age (years)
3.3.2 | T0–T1: Pre-­orthodontic treatment phase
Mean (SE) 47.31 (1.62) 43.49 (2.27) .2

Treated both arches n (%) 21 (84) 23 (92)

No difference in the median % of CAL change was found between test
and control groups. The overview of calculated values for comparison
Treated lower arch n (%) 2 (8) 1 (4) .4
is seen in Table 4.
Treated upper arch n (%) 2 (8) 1(4)
There was a significant difference in mean duration of the ini-
Sex n (%) 16 (64%) women 19 (76%) women
.4 tial (pre-­orthodontic) treatment phase between the test and control
9 (36%) men 6 (24%) men
groups (Table 5).
Smokers ≤5 cig/day n (%) 1 (0.04) 1 (0.04) .8

Dental malocclusion

Angle I 11 10
3.3.3 | T1–T2: Orthodontic treatment phase
Angle II 10 10 .7 Mean 20.6 (95% CI: 18.19; 22.93, range 7–28) teeth in the test group
Angle III 4 5 and 20.84 (18.47; 23.21, range 9–28) were incorporated in ortho-
Mean CAL of sites ≥4 mm dontic appliances (p = .8). Mean OT time did not differ between the
mm (95% CI) 5.28 (5.07, 5.49) 5.24 (5.02, 5.47) .6 groups (Table 5).

% sites CAL ≥4 mm

No difference in CAL change was observed between the test and
control groups after OT. The median % changes of sites for CAL, PD
Mean (SD) 47.6 (18.3) 53.5(19.7)
and REC are seen in Table 4.
Median (IQR) 45.7 (34.1, 57.1) 57.9 (36.5, 70.6) .2

Min–Max 25.0–84.5 17.5–82.1

Mean PD of sites ≥4 mm 3.3.4 | T0–T2: Whole periodontal–orthodontic

mm (95% CI) 4.99 (4.77, 5.22) 4.97 (4.80, 5.15) .9 treatment
% sites PD ≥4 mm Total periodontal–orthodontic treatment duration was signifi-
Mean (SD) 37.4 (17.2) 44.9 (18.4) cantly longer for the control group with mean time difference found
Median (IQR) 32.1 (24.0, 46.8) 48.2 (33.5, 59.5) .1 4.05 ± 1.59 months (Table 5).
Min–Max 14.5–77.1 9.82–82.1 A significant difference between the groups was found in median
Mean REC of sites ≥1 mm % of sites that changed to the lower disease group of PD (Table 4). This

(mm) 95% CI 1.57 (1.27, 1.86) 1.53 (1.24, 1.82) .9

difference was observed in sites with baseline PD of 4–6 mm, which
after combined treatment became <4 mm (Table 6).
% sites REC ≥1 mm
Tooth level analysis of PD change T0–T2 showed no significant
Mean (SD) 21.32 (17.73) 27.46 (19.77)
difference between different teeth and was mean 2.72 (SD 1.25) mm.
Median (IQR) 28.0 (7.7, 42.3) 13.8 (6.5, 35.9) .3
Univariate binary logistic regression analysis revealed statistically
Min–Max 0–80.7 0–66.7
significant association between PD improvement ≥2 mm and tooth
% sites plaque group (anterior/posterior) [OR 2.6; 95% CI: 2.03, 3.211, p = .001],
Median (IQR) 66.7 (46.2, 75.0) 65.9 (55.0, 80.3) .7 sex [OR 1.7; 95% CI: 1.29–2.12, p = .001], age group (≤35/>35 years)
[OR 1.4; 95% CI: 1.03–1.78, p = .03]. Analysis showed multicol-
(continues)
linearity between sex and age group (r = .327, p < .001). Multivariate
 |
220       ZASČIURINSKIENĖ et al.

T A B L E   3   Comparison of clinical
Test patients n = 25 Control patients n = 25
p attachment level (CAL) change between
Variable T0 T2 T0 T2 value test and control group patients before (T0)
and after (T2) periodontal–orthodontic
CAL (mm) (sites ≥4 mm) treatment
Mean (95% CI) 5.28 (5.07, 5.49) 4.85 (4.67, 5.01) 5.24 (5.02, 5.47) 4.81 (4.59, 5.04)
Median (IQR) 5.18 (4.85; 5.64) 4.83 (4.49; 5.11) 5.15 (4.84; 5.58) 4.70 (4.37; 5.05)
Min–Max 4.61–6.39 4.18–5.78 4.51–6.75 4.17–6.17
p = .0001** p = .0001**
CAL CHANGE (mm) (sites ≥4 mm)
Mean (95% CI) 0.44 (0.25, 0.62) 0.38 (0.18, 0.58)
Median (IQR) 0.40 (0.20, 0.59) 0.49 (0.12, 0.62) .59*
Min–Max −0.47 to 1.84 −1.34 to 1.02
CAL LOSS (mm) n = 3 n = 3
(sites ≥4 mm)
Mean −0.21 −0.58
Median −0.14 −0.35 .70*
Min–Max −0.47 to 0.02 −1.34 to 0.06
CAL GAIN (mm) n = 22 n = 22
(sites ≥4 mm)
Mean (95% CI) 0.51 (0.38; 0.64) 0.52 (0.35; 0.70)
Median (IQR) 0.50 (0.32; 0.66) 0.42 (0.27; 0.67) .50*
Min -­Max 0.08–1.2 0.08–1.84

CAL, clinical attachment level; IQR, interquartile range.

*Mann–Whitney U test.
**Wilcoxon signed-­ranks test.

binary logistic regression analysis (overall percentage of the model
72.8%) revealed higher odds ratio for PPD improvement by ≥2 mm
for anterior teeth [OR 2.5; 95% CI: 1.97–3.11, p = .0001] and teeth
in male patients [OR 1.6; 95% CI: 1.18–1.97, p = .001].
As no difference in CAL change (Tables 3 and 4) after combined
periodontal–orthodontic treatment was found between test and con-
trol patients, the null hypothesis was accepted.
4 |  DISCUSSION
The present trial shows the overall favourable results of periodontal–
orthodontic treatment of patients with plaque-­induced periodontitis.
To the best of our knowledge, the present study is the first RCT,
which is designed to analyse two different timings of PT in combina-
tion with OT in patients with plaque-­induced periodontitis. Previously
published clinical studies (Cardaropoli et al., 2001; Corrente et al., 2003;
Melsen, 2001; Melsen, Agerbaek, & Markenstam, 1989; Re, Cardaropoli,
Abundo, & Corrente, 2004) evaluated OT effect on attachment appara-
tus, when surgical PT was completed 1–2 weeks before OT.
4.1 | Main findings
The main clinical finding of the present trial was CAL gain observed in
both groups, in spite of the timing of the PT (Tables 3 and 4). CAL gain
was also reported in a study by Corrente et al. (2003), where intrusion
was used to replace migrated maxillary incisors.
The change of sites with PD ≥4 mm was observed in both groups in
every treatment phase (Table 4). At the end (T0–T2), there were more
sites that changed PD class (healed) in the control than in the test group
(Tables 4 and 6). Classified PD analysis showed that this difference was
mainly in sites with initial PD of 4–6 mm (Table 6). This could probably
be explained by more sites with PD 4–6 mm at T0 in the control group.
The method we used to classify pockets could also influence the re-
sult that PD of 4–6 mm remained in the same class. The pockets that
initially were 6 mm could heal to 4 mm, but we could not see that as
they remained in the limits of the same class. However, deep periodon-
tal pockets (>6 mm) at T0 showed similar improvement in both groups
(Table 6). Nearly half of them healed to the “healthy” status (<4 mm).
In previous studies that were performed on periodontal patients, PD
reduction was also observed (Cardaropoli et al., 2001; Corrente et al.,
2003; Han, 2015; Re, Corrente, Abundo, & Cardaropoli, 2000).
The multivariate binary logistic regression analysis showed greater
chance for PD improvement by ≥2 mm in anterior teeth and teeth
in male patients. As mentioned before, 80% of patients had baseline
proclination of anterior teeth. So, anterior teeth were intruded and
retruded and this could influence difference in soft tissue response
(Figure 3).
Gingival recession is a common consequence of periodontal and
orthodontic treatment (Becker et  al., 2001; Lindhe, Socransky, Nyman,
& Westfelt, 1987; Renkema, Fudalej, Renkema, Kiekens, & Katsaros,
2013). In the present trial, more sites resulted in REC in the control
group at T0–T1, and part of them improved during OT (Table 4). This
could happen due to orthodontic movements, as shown in earlier
ZASČIURINSKIENĖ et al. |
      221

T A B L E   4   Difference between the test and control group patients for changes during T0–T1 (initial periodontal treatment), T1–T2
(orthodontic treatment) and T0–T2 (total treatment) for clinical attachment level (CAL), pocket depth (PD) according to the baseline values
<4 mm, 4–6 mm, >6 mm, development of gingival recessions (REC), reduction in plaque and bleeding on probing (BoP)

Initial periodontal treatment T0–T1 Orthodontic treatment T1–T2 Total treatment T0–T2

Median (Q1–Q3) % Median (Q1–Q3) % Median (Q1–Q3) %

Group sites p value sites p value sites p value

CAL gain Control 6.3 (2.5–14.8) 14.1 (9.7–21.7) 25.0 (18.1–30.7)

.09 .23 .5
Test 4.0 (0–10.6) 17.0 (14.2–21.2) 23.2 (15.3–28.0)
CAL no change Control 93.4 (85.2–96.8) 83.3 (74.9–89.3) 73.2 (67.9–80.9)
.07 .47 .5
Test 96.1 (89.4–100) 82.1 (78.9–84.3) 76.9 (71.1–82.9)
CAL loss Control 0 1.0 (0–2.8) 1 (0–2.2)
.04 .1
Test 0 0 (0–1.7) 0 (0–1.3)
PD reduced Control 31.0 (14.8–45.6) 7.5 (4.3–14.6) 36.4 (24.9–51.2)
.002 .03 .05
Test 8.3 (1.6–23.2) 13.4 (9.8–18.7) 25.0 (16.7–36.5)
PD no change Control 69.0 (54.4–85.3) 86.6 (83.5–94.1) 62.0 (48.8–74.0)
.002 .29 .04
Test 91.7 (76.8–98.5) 85.9 (81.4–89.2) 75.0 (63.5–83.3)
PD increased Control 0 1.4 (0–2.8) 0 (0–1.1)
.001 .2
Test 0 0 (0–0.6) 0
REC Control −27.7 (−40.1 to −5.1) 4.2 (−2.5 to 10.8) −20.2 (−40.0 to −5.3)
development .003 .01 .2
Test −4.2 (−13.8 to 0) −3.6 (−7.4 to 4.4) −10.9 (−20.5 to −1.3)
PLAQUE Control 54.2 (41.0–65.5) 2.6 (−1.2 to 9.4) 57.1 (43.1–71.8)
reduction .74 .69 .9
Test 51.4 (41.6–62.2) 4.2 (0–10.1) 57.1 (45.3–68.7)
BoP reduction Control 73.7 (62.1–82.2) 4.8 (−1.9 to 12.1) 76.2 (68.1–85.2)
.04 .01 .7
Test 60.9 (46.1–76.8) 11.1 (6.4–16.7) 81.0 (66.7–86.0)

CAL, clinical attachment level; PD, pocket depth; REC, gingival recession; BoP, bleeding on probing; Q1, the first quartile; Q3 ,the third quartile; control
group n = 25, test group n = 25; p value by Mann–Whitney U test.

studies (Cardaropoli et al., 2001; Melsen, 2001; Melsen et al., 1989;
Re et al., 2004). For the test group, fewer sites developed REC during
the initial PT. But the changes went in the opposite direction during
OT with an increase in sites with recession development. This could
be related to the PT being performed simultaneous to OT for this
group. After T0–T2, there was no significant difference in median %
of sites with REC development between the groups (Table 4).
Mean OT duration was similar for both groups and is in agreement
with the findings of a recent review article, where the average com-
prehensive OT time was 20 months (Tsichlaki, Chin, Pandis, & Fleming,
2016). Based on the results of the present trial, total treatment time was
significantly longer for the control group patients (Table 5). This differ-
ence for the control group was due to the longer PT phase before OT. If
the treatment duration is important for the patient, based on the find-
ings of this trial, final PT may be postponed and performed during OT.
The cooperation between one orthodontist (EZ) and ten periodon-
tologists was needed to perform the present trial. This can be a limita-
tion but also a strength because it was possible to carry out the trial
in a reasonable time (6 years), and we were not dependent on a single
periodontologist.
Due to the absence of studies with comprehensive OT in patients
with plaque-­induced periodontitis, especially RCTs, we were not able
to compare our findings.
5 | CONCLUSIONS
Both groups showed gain of clinical attachment level (CAL) and re-
duction in sites with probing depth (PD) ≥4 mm. No difference in
REC development between the two groups was observed. Total

T A B L E   5   Treatment time (months) for initial periodontal treatment, orthodontic treatment and total treatment

Initial periodontal Orthodontic treatment T1–T2 Total treatment T0–T2

treatment T0–T1 (months) (months) (months)

Group n Mean ± SE 95% CI p value Mean ± SE 95% CI p value Mean ± SE 95% CI p value

Test 25 1.38 ± 0.18 1.02 1.74 20.30 ± 1.22 17.78 22.83 21.68 ± 1.23 19.15 24.21
.0001 .57 .01
Control 25 4.56 ± 0.35 3.84 5.28 21.17 ± 0.88 19.36 22.98 25.73 ± 1.00 23.66 27.80

CI, confidence interval; p value by Student t test.

222      | ZASČIURINSKIENĖ et al.

T A B L E   6   Distribution of different pocket depth (PD) classes (<4 mm, 4–6 mm, >6 mm) in control (n = 25) and test (n = 25) patients at
registrations before (T0) and after (T2) combined periodontal–orthodontic treatment. Also change of PD class from T0 to T2

T0 T2 T0 and T2 T0–T2

% Sites % Sites % Sites

PD level change
PD (mm) Group Median (Q1–Q3) Median (Q1–Q3) (mm) Group Median (Q1–Q3) p value*

Control 51.8 (40.6–66.5)

<4 and <4a .13
Control 51.8 (40.6–66.5) 90.6 (84.1–95.7) Test 62.5 (50.5–74.0)
<4 Control 0 (0–1.1)
<4 and 4–6b .14
Test 69.4 (54.7–76.4) 93.8 (87.7–95.3) Test 0
Control -­
<4 and >6b -­
Test -­
Control 30.4 (18.8–45.9)
4–6 and <4c .03
Control 40.9 (26.8–50.0) 9.4 (4.3–15) Test 20.5 (13.6–25.5)
4–6 Control 6.5 (2.8–10.7)
4–6 and 4–6a .29
Test 26.4 (19.8–33.7) 6.0 (3.9–11.5) Test 4.5 (2.8–7.2)
Control -­
4–6 and >6b -­
Test -­
Control 1.3 (0–5.0)
>6 and <4c .52
Control 4.0 (1.0–8.7) 0 Test 1.1 (0–2.9)
>6 Control 1.2 (0–6.1)
>6 and 4–6c .69
Test 3.6 (1.1–6.7) 0 Test 2.0 (0–3.1)
Control -­
>6 and >6a -­
Test -­

PD, pocket depth; Q1, the first quartile; Q3, the third quartile; control group n = 25; test group n = 25; T0, baseline; T2, after total treatment.
a
No change.
b
Increase.
c
Decrease.
*p value by Mann–Whitney U test.

(a) (f)

(b)

(c)

(d)

(e)

F I G U R E   3   Treatment progress of Angle II-­1 patient with plaque-­induced periodontitis baseline (a), after periodontal treatment (b), during
orthodontic treatment (c, d) and after treatment (e) with straight-­wire mechanics and microimplant used for anchorage. Periapical radiograph at
baseline (f)
ZASČIURINSKIENĖ et al.
periodontal–orthodontic treatment time was significantly longer for
the control group, where the final periodontal treatment was per-
formed before the orthodontic treatment. Based on the results of this
trial, we conclude that orthodontic treatment, simultaneously to the
periodontal treatment, could be used in the routine treatment of pa-
tients with plaque-­induced periodontitis.
ACKNOWLE DG E MEN TS
The authors acknowledge Prof. A.Šidlauskas; the periodontolo-
gists, especially G.Naumavičius; dental hygienists; dental assistants
Vita and Audronė. The authors acknowledge statisticians PhD
B.Ljungquist and I.Nedzelskiene for the contribution to statistical
analysis.
CO NFLI CT OF I NTE RE ST
No external funding—except support from the authors’ institution—
was available for this study. We declare that we have no conflict of
interest in this study.
O RCI D
Eglė Zasčiurinskienė  http://orcid.org/0000-0001-8364-0510
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Lindsten R, Slotte C, Jansson H, Bjerklin K. Orthodontic
treatment simultaneous to or after periodontal cause-­related
treatment in periodontitis susceptible patients. Part I: Clinical
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