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Oral tissues and orthodontic treatment: Common side effects

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MINERVA STOMATOL 2013;62:431-46

Oral tissues and orthodontic

treatment: common side effects
G. FARRONATO, L. GIANNINI, G. GALBIATI, P. CANNALIRE

® A
G. MARTINELLI, I. TUBERTINI, C. MASPERO

T C
H DI
The aim of this paper was to provide a lite- Department of Orthodontics
rature review about the problems that can Fondazione IRCCS Cà Granda
occur during orthodontic treatment. Using University of Milan, Milan, Italy
IG E
the PubMed database we collected items
that would provide information regarding
the direct consequences of the placement
R M
of an orthodontic appliance: coming to the
discussion of the following topics: candida intercept these issues not to affect the suc-
infections, the effects on the soft tissues, cess of the treatment.
the effects on periodontal tissues and ef- Key words: Adverse effects - Orthodontics - ���
Pa-
P A

fects on hard tissues. The presence of ap- thology, oral.

pliances in the oral cavity increases the pre-
O V

valence of people with candida, specifically

the species Candida Albicans is the most
frequently isolated. The balance between
T he progress of medicine, which has led
C ER

the clearance of the microorganism, the co- to an increase in life expectancy, has re-
lonization and the state of candidiasis de- sulted in an increased demand for dental
Y

pends both on the virulence of the fungus,

and the competence of the host immune sy- care.1 For this reason, the basis of proper
stem. On soft tissues, cases of ulceration of therapy must have the psycho-social ap-
IN

the upper jaw by a rapid palatal expander
and pyogenic granuloma due to quad helix
appliance have been reported. The second
one is mostly observed on vestibular gin-
M
pearance of each patient, in order to know
the stressors related to his expectations,
motivations and needs.2 It is therefore im-
portant to give the patient the opportunity

giva. The first one was found, however, in

patients suffering from diabetes mellitus
type 1 because of the tissue modifications
induced by this pathological condition. The
more severe periodontic effects are tho-
se caused by incorrect use of orthodontic
or other proprietary information of the Publisher.
to understand the limitations of therapy,
informing them about the advantages and
disadvantages of the planned treatment.3
In particular, the orthodontist must be

elastic separators. Finally, the White Spot

Lesions are the direct consequences of a
wrong conditioning of enamel when atta-
ching the bracket. They represent a first
stage of caries in the positioning area of
the bracket. The orthodontist is required to
Corresponding author: G. Farronato, Cà Granda IRCCS
Foundation, Via Commenda 10, 20122 Milan, Italy.
E-mail: giampietro.farronato@unimi.it
aware of all the possible clinical implica-
tions of such treatment. He, in fact, meeting
his patients at intervals of 6-8 weeks, has
the opportunity to intercept earlier the on-
set of any complications resulting from the
treatment. A complete medical history and
dental surgery should be performed and
updated regularly.
The orthodontic treatment has the pur-

Vol. 62 - No. 11-12 MINERVA STOMATOLOGICA 431

not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO ORAL TISSUES AND ORTHODONTIC TREATMENT
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
pose of improving oral health, aesthetics
and function. In addition to the expected
results, however, there may be unintended
side effects.
Changes of local conditions, hypotheti-
cally related to orthodontic treatment, may
result in adverse effects on the tissues, the
presence of which may interfere with the
timing of prognosis and with the quality of
the therapy.4
The objective of this article is to provide
a literature review about the problems that
® A
may arise in the course of orthodontic treat-
ment, also illustrating some diseases associ-
T C
ated with skeletal and dental anomalies, and
therefore important in orthodontic practice.
H DI
Materials and methods
IG E
The systematic review of the literature
was conducted through the use of the
R M
PubMed database. The keywords entered
are “oral pathologies after orthodontic
treatment” (209 articles) and “orthodontic
treatment oral pathologies” (535 items).
P A
Only articles that would provide informa-
tion regarding the direct consequences of
O V
the placement of an orthodontic appliance
coming to the discussion of the following
C ER
topics were considered:
—— the candida infections;
Y
—— the effects on the soft tissues;
—— the effects on periodontal tissues;
IN
—— the effects on hard tissues.
Results
M
We divide now the problems that emerged
from our systematic review of the literature,
which may arise from the orthodontic treat-
or other proprietary information of the Publisher.
ment and may therefore affect the success
of the same one.
Candida infections
Candida is an opportunistic pathogen
present in about 50-60% of the human pop-
ulation.5
Many studies demonstrate the relation-
432 MINERVA STOMATOLOGICA November-December 2013
ship between the presence of the micro-
organism and caries prevalence 6 and peri-
odontal condition.7
Oral colonization varies from individual
to individual and by geographic location; it
has been isolated from dental plaque, hu-
man dental hard tissues and sub-gingival
flora.8
Prevalence of candida carriers
In a review of 41 studies by Odds,9 the
four highest frequencies reported were:
71% and 54% respectively among school-
children and infants in UK, 56% among Is-
raelian children and 69% in nursing staff in
Germany.
It has been reported that the presence of
a fixed orthodontic appliance (FOA) such as
full or partially removable dentures predis-
poses to an increase in carriage of microbes
and subsequent infections.10 Thus, Truchot
(1991) demonstrated a link between an in-
creased level of plaque in those treated with
FOAs and the consequent development of
gingivitis.11 These subjects are also more
prone to periodontal disease,12 to loss of of
periodontal support 13 and carious lesions on
both facial and lingual aspect of the teeth.14
Hagg et al.15 reported a study to assess
significant quantitative and qualitative al-
terations in the carrier rate of Candida
and Enterobacteriaceae and the associated
changes in the plaque index in a Chinese
adolescent population with healthy mouths
before and during FOA therapy. All individ-
uals received oral hygiene and dental floss-
ing instruction. Plaque indices were record-
ed as indicators of oral status using criteria
of Silness and loe (1964). The oral candidal
carriage rate was evaluated using three dif-
ferent standardized techniques: the imprint
culture, oral rinse and the pool plaque
method. The first one was used to deter-
mine the candidal colonization of oral mu-
cosa, the second one for the quantification
of candida species and enterobacteriaceae
and the third one to identify the species
present in samples. This study indicates an
initial low plaque index and total bacterial
count for the baseline patient group, how-
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
ORAL TISSUES AND ORTHODONTIC TREATMENT FARRONATO
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
ever after insertion of FOA, a 10% mean
increase in the plaque index was noted. It
also demonstrated that candida carriage did
significantly increase (27%) after the inser-
tion of the fixed appliances detected with
imprint culture technique.
Similar changes in plaque accumulation
during orthodontic treatment with remova-
ble16,17 and fixed appliances 18, 19 have been
reported by several authors.
In particular Addy et al.17 presented a
long term study on patients treated with
® A
removable appliances. The candida carriers
before treatment was 39%; after 9 months, it
T C
had increased 79% and after treatment was
reduced to 14%. Thirteen of the 33 patients
H DI
converted from non-carriers to carriers dur-
ing the therapy, but ten patients converted
back to non-carriers after the removal of
appliances. IG E
In a recent study comprising 112 ortho-
dontic patients treated with fixed applianc-
R M
es, 32% carried candida before treatment,
and it increased gradually to 50% at the fifth
month and remained on that level for the
rest of the observation period, similar to
P A
that reported in the study presented by Ars-
lan et al.,20, 21 who, however were unable to
O V
report on the number of non-carriers con-
verted to carriers after the insertion of fixed
C ER
appliances.
However, in the study conducted by Lee
Y
et al.,22 the increase in frequency of candi-
dal carriers was not significant.
IN
In contrast, Sinclair et al.23 showed no sig-
nificant differences between pre-treatment
and the insertion of FOA in 13 adolescents,
supported by Davies et al.24 He demonstrat-
M
ed a significant reduction in all plaque and
gingival indices between baseline and the 3
years examination in both the orthodonti-
cally treated and non-treated groups.
or other proprietary information of the Publisher.
Site prevalence
The removable appliances protect the
candida from the natural and mechanical
removal of the saliva, whereas fixed appli-
ances do not cover the mucosa so, as ex-
pected, have the candidal distribution simi-
lar to that of non-appliance wearers.20
Vol. 62 - No. 11-12 MINERVA STOMATOLOGICA 433
The most frequent site for candida iso-
lation in non-appliance and fixed appli-
ance wearers was the posterior part of the
tongue,16, 17 whereas for removable appli-
ance wearers was the posterior and anterior
palatal site.17 After the removal of the ortho-
dontic appliance, the prevalence of candida
returned to levels not significantly different
from those before treatment.20
Prevalence of different candida species
The most frequent candida species iso-
lated in several studies is candida albi-
cans.15, 24, 26 Similar findings have been dem-
onstrated by Arslan et al., in which study on
south-eastern Turkish adolescents C. Albi-
cans was the most frequent species (73.8%)
followed by C. tropicalis, C. krusei, C. kefyr
(7.14%) and C. parapsiloris (4.76%)8.
The effect of appliances on oral hygiene:
It is shown that the insertion of an or-
thodontic appliance into the oral cavity
increases the number of plaque retention
areas.27, 28
Addy et al.16 showed that the total mouth
plaque scores for the non-appliance and
removable appliance wearers were not sig-
nificantly different.
For the removable appliance wearers,
however, the palatal plaque scores were
significantly increased, whereas the buccal
score decreased when compared with the
respective surfaces in non-appliance wear-
ers.20 It may be that the removable appli-
ance protects the plaque from natural and
mechanical removal. similar, but reduced
effect was noted by Arendorf and Addy.17
Hagg et al.15 also noted the increase in the
plaque score with 10% increase after the
insertion of fixed appliance. This could be
caused by the presence of orthodontic at-
tachments, thus the difficulty in brushing
the teeth well with the orthodontic attach-
ments on the tooth surfaces. In a long-term
follow up study by Arslan et al., the candida
counts in patients undergoing orthodontic
treatment with fixed orthodontic appliances
gradually increased when monthly means
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO ORAL TISSUES AND ORTHODONTIC TREATMENT
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
were considered. The increases in candida
counts in the saliva, and upper and lower
jaw were statistically significant, excluding
the 6th and 12th month comparison.8
However some studies show that there
was no significant difference in plaque
accumulation between pretreatment and
the insertion of fixed orthodontic appli-
ance:23, 24 the behavioural factor in main-
taining good oral hygiene may be a more
important factor. A study 29 conducted in
Hong Kong concluded that the presence of
® A
an appliance can hinder the patient from
maintaining good oral hygiene other than
T C
the behavioural factor. However, there is no
direct evidence to demonstrate that poor
H DI
oral hygiene leads to candidal carriage as
not all studies show the insertion of appli-
ances leads to an increase in plaque ac-
cumulation, but there is an increase in the
IG E
density of candida.
Brusca et al.30 found that the adherence
R M
of candida albicans was most with candida
brackets, followed by ceramic then metal-
lic. This is because the microorganism find
a highly favourable ecological niche in the
P A
more porous and less smooth structure of
the bracket material. How this difference in
O V
the adherence to different bracket materi-
als influence the candidal carriage rate and
C ER
candida density has not been studied.
Y
Candidal colonization and candidosis
IN
Candida albicans is frequently found in
human mouth, but only few carriers de-
velop clinical signs of candidosis. Oral can-
didosis results from yeast over-growth and
M
penetration of the oral tissues when the
host’s physical and immunological defences
have been undetermined. the most critical
thing that determines whether clearance,
or other proprietary information of the Publisher.
colonization or candidosis is the host’s im-
mune competence.20
Cannon et al.31 found that without attach-
ment, the growth rate of C. albicans is in-
sufficient to mantain carriage in the mouth.
Progression to a mucosal infection depends
on adherence and growth rate, but also in-
volves tissue penetration. For an infection
to persist, the host immune system must
434 MINERVA STOMATOLOGICA November-December 2013
fail, to contain the growth of the yeast. the
balance among clearance colonization or
candidosis therefore depends on the ability
of candida strains to modulate expression
of virulence factors in response to environ-
mental change, combined with competence
of the host immune system. Host factors re-
ported to be associated with increased oral
carriage rates of Candida include: xerosto-
mia,32 low saliva ph,33 smoking,33 increased
saliva glucose concentration,34 old age.35, 36
The prevalence of candida species is high-
er in the immunocompromised patients;37
factors that affect host immunity are AIDS,
malignancy, anticancer treatment and long-
term antibiotic treatment which can cause
C. albicans overgrowth in the oral cavity by
eliminating competing microorganism.
Soft tissues
Maxillary ulceration and diabetes
Hyperglycemia modifies metabolic bal-
ance, promoting several alterations in vas-
cular tissues, reduced neutrophil efficien-
cy,38 increased connective and bone-tissue
destruction and an exacerbated promotion
of inflammatory mediators.38-42 In the mouth
these factors lead to progressive and in-
creased severity of periodontal disease.41, 43
In the initial phase there is predominance
of gingivitis and periodontitis, with possi-
ble evolution to advanced periodontal dis-
ease.41, 42, 44 The main alterations found in
the saliva are reduced production and al-
tered composition correlated to increase of
glucose, proteins and α-amilase levels 45 and
they can cause ulcers, cheilitis and fissured
tongue.40, 46 The greater amount of glucose
in the saliva and crevicular gingival fluid
stimulates bacterial growth, reduces the fi-
broblast capacity to promote healing and
increases the production of lactic acid. Type
1 DM promotes retarded osseous regenera-
tion, weakening of the periodontal ligament,
microangiopathies in gingival area.47, 48 The
reduced new bone formation capacity is
owing to apoptosis of fibroblastic and oste-
oblastic cells in diabetic individuals.49
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
ORAL TISSUES AND ORTHODONTIC TREATMENT FARRONATO
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Some case reports have been published
on life-threatening deep infections from
periodontal abscess 50 and fatal maxil-
lary ulceration in patients with diabetes
mellitus (the ulcers were not superficial
but represented deep granulomatous dis-
ease).51
Maia et al.52 showed the reaction from
the use of a rapid maxillary expander in a
9-year-old patient. Four days after cement-
ing the RME, the child returned for reas-
sessment complaining maxillary discomfort,
® A
bleeding and localized continuous pain.
Examination revealed necrotic ulceration,
T C
hemorragic aspect from the first permanent
molar through the first primary molar, ex-
H DI
tensive inflammation of the entire palate,
with partial redraping of the acrylic part
by the mucus. The appliance was removed
and the child was monitored every 3 days
IG E
to assess ulcer regression. The patient was
referred for medical assessment and the ex-
R M
ams showed the patient had type 1 diabetes
mellitus (DM).
So the oral cavity may show the first signs
or symptoms of an undiagnosed or poorly
P A
controlled diabetic condition.40, 53-55 Glyc-
emic control in DM management, is a key
O V
to reducing the impact of acute oral infec-
tions and microvascular complication 40, 41
C ER
and for diabetic patients under good medi-
cal control, all dental procedures can be
Y
performed.38, 40, 42, 53
IN
Pyogenic granuloma
A pyogenic granuloma is a “particular
type of inflammatory hyperplasia”56 which
M
arises as a side effect associated with the
use of a fixed quad helix orthodontic appli-
ance. It is a fixed device which allows dif-
ferential anterior and posterior expansion57
or other proprietary information of the Publisher.
and it was described by Ricketts in 197958.
Risks associated with the use of such appli-
ance are short term risks (altered speech59,
soft tissue irritation or ulceration commonly
involving the tongue and general discom-
fort) or long-term risk (gingivitis around
molar teeth, caries, root resorption and
catastrophic dental tipping). Only a few au-
thors have made studies of this rare compli-
Vol. 62 - No. 11-12 MINERVA STOMATOLOGICA 435
cation. In 2002 Kneafsey et al reported the
spontaneous resolution of a developing py-
ogenic granuloma by removal of the quad
helix. The lesion measured approximately
1x6 mm and developed over a 6-months
period60.
In the case described by Acharya in
201161 the lesion was almost twice the size
(1 cm2) and developed over a 4-months
period. It was located in the posterior left
side of the tongue and its surface showed
the clear indentation of the quad helix with
associated ulceration and glossal keratosis/
plaque accumulation. Treatment involved
surgical resection of the mass, followed by
histological confirmation. It was supported
by oral hygiene instruction and the removal
of the fixed appliance.
The lesion usually appears as smooth
or lobulated, pedunculated masses with
rough, ulcerated surfaces. Their size varies
from few millimeters to several centime-
tres in diameter. Clinically they are typi-
cally painless and often bleed easily62,63.
The most common presenting site is the
maxillary anterior labial gingiva56,63, fol-
lowed by lips, dorsal surface of the tongue
and buccal mucosa56,63,64. Females aged
11-40 years are particularly at risk of de-
veloping such lesions due to hormonal
influences56,63. A commonly known form
is the “pregnancy epulis”63 that can occur
during pregnancy and is predisposed by
high levels of circulating progesterone and
estrogen.
Effects on periodontal tissues
Localized periodontitis and periodontal
abscesses can be associated with a variety
of dental material such as silicone impres-
sion material,65, 66 rubber dam (Greenbaum
et al.),67 and even self-inflicted gingival in-
jury due to habitual fingernail biting (Krejci
et al.).68
Several millimeters of periodontal attach-
ment and alveolar bone can be lost within
as little as a few days. The onset is sudden
and accompanied by an acute inflammatory
response; a painful gingival swelling may
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO ORAL TISSUES AND ORTHODONTIC TREATMENT
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
occur around the affected teeth and, de-
pending on the severity of the infection, the
patient may experience regional lymphad-
enitis, malaise or fever69.
Waggoner et al.70 reported how rubber
band that slips undetected under the gin-
giva, might move along the roots, resulting
in significant loss of alveolar bone. Other
authors supported these findings such as
Zager and Barnett,71 who in 1974 reported
a case of bone loss caused by multiple or-
thodontic rubber bands, and Zilberman et
® A
al.,72 who showed a case of iatrogenic teeth
exfoliation due to the incorrect use of such
T C
devices.
Also Becker et al.73 highlight the potential
risks in a healthy patient whose prepara-
H DI
tion for orthodontic treatment consisted of
orthodontic separators. He presented swell-
ing, accompanied by white ulcers. Some X-
IG E
ray showed the displaced elastic separator,
which was removed by periodontal curet-
R M
tage.
Hard tissues: white spot
P A
lesions and caries
O V
The use of orthodontic appliances and
the conditioning of enamel surface by
C ER
etching with phosphoric acid to achieve
microretention for bonding brackets with
Y
composite adhesive systems are common
components of fixed orthodontic therapy.
IN
Enamel demineralization is a significant
risk associated when oral hygiene is poor.
The Prevention of this damage is one of
the greatest challenges faced by clinicians:
M
the development of white spot lesions is at-
tributed to prolonged plaque accumulation
around the brackets.74-78 Not only do fixed
appliances make conventional oral hygiene
or other proprietary information of the Publisher.
procedures more difficult, they also increase
the number of plaque retention sites on the
surfaces of the teeth that are normally less
susceptible to caries development.79 White
spot lesions are not only disturbing estheti-
cally, especially in the anterior teeth,80 but
also are an initial stage of enamel caries,
producing outer enamel layers 81 with sig-
nificantly reduced mineralization that will
436 MINERVA STOMATOLOGICA November-December 2013
progress to a stage at which restoration
will be needed, if inadequate oral hygiene
prevails.82 Previous experiments on bovine
enamel suggested that white spot lesions
might be triggered iatrogenically under
some circumstances such as surplus etching
of enamel areas that are subsequently not
covered by brackets bases or bonding ma-
terial.83 This can be especially severe in the
teeth in which almost the complete facial
enamel surface is etched but subsequently
incompletely covered by bonding materials
or sealers.
WLSs can be noticeable around the brack-
ets within 1 month (as reported by Ogaard
et al.) of bracket placement, although the
formation of regular caries usually takes at
least 6 months.84
Prevalence
A review of available literature on the
prevalence of WLS revealed that most rele-
vant studies reported the presence of these
lesions at the completion of orthodontic
treatment.
Depending on the examination technique
used, the prevalence varies.
Gorelick et al.,74 using the visual exami-
nation technique, reported that 50% of the
patients had one or more WLSs at the end
of the treatment.
Boersma et al.,85 using quantitative light
fluoroscopy, reported a percentage of 97%.
Early detection of WLSs is of great impor-
tance, as it would allow clinicians to imple-
ment preventive measures.
Tufekci et al.86 reported in their study
that 38% of the subjects had a visual WLS
6 months into treatment, this number in-
creased to 46% for 12-month evaluation.
Only 11% of the control group presented
with at least one white spot lesions. A high-
er prevalence in the study by Gorelick et al
may be attributed to the inclusion of both
maxillary and mandibular teeth, and to the
length of the orthodontic treatment (about
24 months), as opposed to the examination
of the maxillary teeth from canine to canine
at 6 and 12 months into orthodontic treat-
ment.
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
ORAL TISSUES AND ORTHODONTIC TREATMENT FARRONATO
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Distribution on different teeth and between
males and females
In the literature, conflicting reports have
described the distribution of WLSs: Gorelick
et al74 reported that the tooth most com-
monly affected was the maxillary lateral
incisor. On the other hand, Mizrahi 87 con-
cluded that the maxillary and mandibular
first molars were the teeth most commonly
affected. Ogaard 78 agreed with Mizrahi’s
conclusions. In contrast, Geiger et al.77 re-
® A
ported that lesions occurred most frequent-
ly on maxillary lateral incisors and canines.
T C
Tufekci et al.,86 however, found no signifi-
cant differences among teeth at 6 months,
H DI
at 12 months, or on the day of bonding
(control).
Another interesting finding is the over-
whelming difference between the preva-
IG E
lence of white spot lesions in males and
females. In the study by Tufekci et al.,86 of
R M
subjects who had at least one white spot
lesions, 76% were male. These findings dif-
fer from Gorelick’s findings,74 in which the
incidence was 44% for boys and 54% for
P A
girls. However a more recent study by Bo-
ersma 85 found that 40% of the buccal sur-
O V
faces in males had demineralization com-
pared with 22% in females. So, one possible
C ER
explanation for these results is that females
are generally more compliant orthodontic
Y
patients.88, 89
A microscopic analysis done by Teodora
IN
Preoteasa et al.90 (performed by using the
high precision steromicroscope on nine
extracted teeth), revealed the presence of
changes both in the buccal surface of the
M
crown of maxillary premolars with a history
of orthodontic treatment, where the bracket
was bonded, and in the apical part of the
root, as an indirect effect of the tooth move-
or other proprietary information of the Publisher.
ment.
In terms of color there was found an ir-
regular aspect with a clear identification of
the area where the bracket was applied: the
enamel area corresponding to the bracket’s
base presented a uniform white aspect,
whereas the area corresponding to the
bracket’s margins was assessed as having
color changes (lighter and darker changes).
Vol. 62 - No. 11-12 MINERVA STOMATOLOGICA 437
In addition, the enamel area correspondent
to bracket base was assessed as having a
surface roughness higher than the adjacent
buccal and lingual surfaces (used as con-
trol). Regarding the apical part of the root,
all teeth with a history of orthodontic treat-
ment presented a highly irregular contour,
with interruption of the continuity of the
hard dental structure. Multiple lacunas with
different depths were identified, the general
appearances being integrated to the pres-
ence of apical root resorption. In contrast,
the aspect of root surface of the teeth from
the control group was very different: it was
assessed as uniform, with a linear apical
shape, not being identified resorption gaps.
The major findings of the study by Kno-
sel et al.,83 was that there is also a white
spot lesion formation enhancing effect from
the duration of etching before orthodon-
tic bracket placement. There was a clearly
significant effect on lesion formation and
progression with etching duration exceed-
ing 15 seconds, especially without adequate
enamel brushing. Previous research has
indicated that etching duration of 15 sec-
onds are sufficient for adequate shear bond
strength for orthodontics purposes.
Discussion and conclusions
This review of the literature shows that
orthodontic treatment may have conse-
quences on the periodontal ligament, hard
and soft tissue, also causing yeast infections.
—— With regard to the latter issue, most
authors believe that the presence of both
fixed and mobile equipment increases the
prevalence of carriers of candida, espe-
cially the species Candida Albicans is the
most isolated. The most affected sites are
the back of the tongue in untreated subjects
and in patients FOA, whereas in subjects
with mobile devices the mainly exposed
seat is the palate. After removal of the de-
vices, however, the prevalence comes back
to the levels prior to treatment. Also dem-
onstrating the presence of the microorgan-
ism in the oral cavity, it is not said that the
subject developments candidiasis. This is
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO ORAL TISSUES AND ORTHODONTIC TREATMENT
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
because the balance between the clearance
of the microorganism, the colonization and
the state of candidiasis depends both on the
virulence of the fungus, on the competence
of the host immune system.
—— On soft tissue ulceration of the max-
illa due to treatment with the rapid palatal
expander 91 in patients with type 1 diabetes
mellitus. Hyperglycemia due to this disease
alters the metabolic balance leading to the
tissue changes responsible for these inju-
ries. Another rare complication taken into
® A
consideration is the pyogenic granuloma
following the placement of a quad helix ap-
T C
pliance. It is more common to load the ves-
tibular gingiva ranging in size from a few
H DI
millimeters to several centimeters in diam-
eter.
—— The orthodontic elastic separators,
as well as other dental devices can cause
IG E
problems with periodontitis. Have been
published cases of bone attachment loss
R M
due to displaced elastic separators, but also
much more serious cases of iatrogenic exfo-
liation of the tooth. Is therefore essential the
radiographic diagnosis in order to intercept
P A
this type of problem correctly.
—— The enamel demineralization is a
O V
common risk due to incorrect conditioning
of the tooth surface with etching and adhe-
C ER
sive systems for fixing orthodontic brackets.
The development of so-called white spot
Y
lesion is associated with prolonged accu-
mulation of plaque around brackets. Hence
IN
the importance of proper oral hygiene, to
prevent the manifestation of such lesions
that represent a first stage of caries. The
WSL become visible one month after band-
M
ing, while the development of caries usu-
ally takes 6 months. It is reported by several
studies such as excessive duration of etch-
ing, especially if not completely covered by
or other proprietary information of the Publisher.
sealers and adhesives composites, can lead
to the appearance of these unsightly con-
sequences.
It is therefore important that the ortho-
dontist knows how to catch all these com-
plications that can affect the success of
the orthodontic treatment,92-98 requiring at
worst discontinuation of therapy before its
completion.
438 MINERVA STOMATOLOGICA November-December 2013
References
  1. Farronato G, Giannini L, Galbiati G, Sesso G, Maspe-
ro C. Orthodontic-surgical treatment: neuromuscular
evaluation in skeletal Class II and Class III patients.
Prog Orthod 2012;13:226-36.
  2. Farronato G, Giannini L, Galbiati G, Maspero C.
Long term results of open reduction management of
condylar fracture: a 20 years follow-up. Case report.
Minerva Stomatol 2012;61:457-65.
  3. Farronato G, Giannini L, Galbiati G, Maspero C.
Modified Hyrax expander for the correction of up-
per midline deviation:a case report. Minerva Stoma-
tol 2011;60:195-204.
  4. Farronato G, Carletti V, Giannini L, Farronato D,
Maspero C. Juvenile Idiopathic Arthritis with tem-
poromandibular joint involvement: functional treat-
ment. Eur J Paediatr Dent 2011;12:131-4.
  5. Samaranayake LP, MacFarlane TW. An in vitro study
of the adherence of Candida albicans to acrylic sur-
faces. Arch Oral Biol 1980;25:603-9.
  6. Uyugun-Can B, Kadir T, Akyuz S. Oral candidal car-
riage in children with and without dental caries.
Quintessence Int 2007;38:45-9.
  7. Urzua B, Hermosilla G, Garmonal J, Morales-Bozo
I, Canals M, Barahona S et al. Yeast diversity in oral
microbiota of subjects with periodontitis:Candida al-
bicans and Candida dubliniensis colonize the peri-
odontal pockets. Med Mycol 2008;8:1-11.
  8. Arslan S. G, Akpolat N, Kama J. D, Ozer T, Hamamc
O. One-year follow-up of the effect of fixed ortho-
dontic treatment on colonization by oral candida. J
Oral Pathol Med 2008;37:26-9.
  9. Odds FC. Candida and candidosis:a review and bib-
liography. London: Baillere Tindall; 1988. p. 10-50.
10. Atack NE, Sandy JR, Addy M. Periodontal and micro-
biological changes associated with the placement
of orthodontic appliances. A review. J Periodontol
1996;67:78-85.
11. Truchot G. Do multi-bracket orthodontic appliances
favor the development of parasites and fungi in the
oral environment? Pathological and therapeutic con-
sequences. Orthod Fr 1991; 62:1019-24.
12. Petti S, Barbato E, Simonetti D’Arca A. Effect of or-
thodontic therapy with fixed and removable appli-
ances on oral microbiota:a six-month longitudinal
study. Microbiologica 1997;20:55-62.
13. Hamp S E, Lundstrom F, Nyman S. Periodontal con-
ditions in adolescence subjected to multiband or-
thodontic treatment with controlled oral hygiene.
Eur J Orthod 1982;4:77-86.
14. Ogaard B. Prevalence of white spot lesions in
19-year-olds. A study on untreated and orthodonti-
cally treated persons five years after treatment. Am J
Orthod Dentofacial Orthop 1989;96:423-7.
15. Hagg U, Kaveewatcharanont P, Samaranayake YH,
Samaranayake LP. The effect of fixed orthodontic
appliances on the oral carriage of Candida species
and Enterobacteriaceae. Eur J Orthod 2004;26:623-9.
16. Addy M, Shaw W C, Hansford P, Hopkins M. The
effect of orthodontic appliances on the distribution
of Candida and plaque in adolescence. Br J Orthod
1982;9:158-63.
17. Arendorf T, Addy M. Candidal carriage and plaque
distribution before, during and after removable
orthodontic appliance therapy. J Clin Periodonol
1985;12:360-8.
18. Boyd RL. Longitudinal evaluation of a system for
self-monitoring plaque control effectiveness in or-
thodontic patients. J Clin Periodontol 1983 10:380-8.
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
ORAL TISSUES AND ORTHODONTIC TREATMENT FARRONATO
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
19. Alexander SA. Effects of orthodontic attachments on
the gingival health of permanent second molars. Am
J Orthod Dentofacial Orthop 1991;100:337-40.
20. Hibino K, Wong RWK, Hagg U, Samaranayake LP.
The effects of orthodontic appliances on Candida in
the human mouth. Int J Paediatr Dent 2009;19:301-8.
21. Arslan SG, Akpolat N, Kama JD, Ozer T, Hamamci
O. One-year follow-up of the effect of fixed ortho-
dontic treatment on colonization by oral Candida. J
Oral Pathol Med 2008;37:26-9.
22. Lee W, Low BKM, Samaranayake LP, Hagg U. Geno-
typic variation of Candida albicans during ortho-
dontic therapy. Front Biosci 2008;13:3814-24.
23. Sinclair PM, Berry CW, Bennet CL, Israelson H.
Changes in gingiva and gingival flora with bonding
and banding. Angle Orthod 1987;57:271-8.
® A
24. Davies TM, Shaw WC, Worthington HV, Addy M,
Dummer P, Kingdon A. The effect of orthodontic
treatment on plaque and gingivitis. Am J Orthod
Dentofacial Orthop 1991;99:155-61.
T C
25. Budtz-Jorgensen E. Candida-associated denture sto-
matitis and angular cheilitis In: Samaranayake LP,
Macfarlane TW, editors. Oral candidosis. London:
H DI
Wright; 1990. 156-83.
26. Pacal-Yesilbag G, Altug Z, Kalkanci. A Evaluation on
the candida colonization on the surface of ortho-
dontic braces and the adhesionof the strainsto buc-
cal ephitelial cells. Turkish J Orthod 2003;16:157-60.
IG E
27. Cannon RD, Chaffin WL. Oral colonization by Can-
dida albicans. Crit Rev Oral Biol Med 1999;10:359-
R M
83.
28. Calderone R, Suzuki S, Cannon R, Cho T Candida
albicans adherence, signaling and virulence. Med
Mycol 2008;38:125-37.
29. Kwan E. Oral health status of 13 and 15 year-old
secondary school in Hong Kong. ���������������
Hong Kong: Uni-
P A
versity of Hong Kong; 1992.
30. Brusca MI, Chiara O, Sterin-Borda L, Rosa AC. In- ���
fluence of different orthodontic bracket on ad-
O V
herence of microorganism in vitro. Angle Orthod
2007;77:331-6.
31. Cannon RD, Holmes AR, Mason AB, Monk BC. Oral
C ER
candida: clearance, colonization or candidiasis? J
Dent Res 1995;74:1152-61.
Y
32. Parvinen T, Larmas M. The relation of stimulated
salivary flow rate and pH to Lactobacillus and yeast
concentration in saliva. J Dent Res 1981;60:1929-35.
33. Arendorf TM, Walker DM. The prevalence and intra-
IN
oral distribution of candida albicans in man. Arch
Oral Biol 1980;25:1-10.
34. Knight L, Fletcher J. Growth of candida albicans
in saliva: stimulation by gloucose associated with
antibiotics, corticosteroids, and diabetes mellitus. J
M
Infect Dis 1971;123:371-7.
35. Sugimoto J, Kanehira T, Mizugai H, Chiba I, Morita
M. Relationship between salivary Histatin 5 levels
and Candida CFU counts in healthy elderly. Gerod-
ontology 2006;23:164-9.
36. Shimizu C, Kuriyama T, Williams DW, Karasawa
or other proprietary information of the Publisher.
T, Inoue K, Nakagawa K et al. Association of oral
yeast carriage with specific host factors and altered
mouth sensation. Oral Surg Oral Med Oral Pathol
2008;105:445-51.
37. Lin AL, Johnson DA, Patterson TF, Wu Y, Lu DL,
Shi Q et al. Salivary anticandidal activity and saliva
composition in an HIV-infected cohort. Oral Micro-
biol Immunol 2001;16:270-8.
38. Mealey B. Diabetes and periodontal disease. J Peri-
odontol 1999;70:935-49.
39. Alves C, Andion J, Brandao M, Menesez R. Mecan-
ismos patogenicos da doenca periodontal asociada
Vol. 62 - No. 11-12 MINERVA STOMATOLOGICA 439
ao diabetes melito. Arq Bras Endocrinol Metabol
2007;51:1050-7.
40. Bensch L, Braem M, Willems G. Orthodontic con-
siderations in the diabetic patient. Semin Orthod.
2004;10:252-8.
41. Ryan ME, Carnu O, Kamer A. The influence of dia-
betes on the periodontal tissues. J Am Dent Assoc.
2003;134:34S-40S.
42. Vernillo AT. Dental considerations for the treatment
of patients with diabetes mellitus. J Am Dent Assoc
2003;134:24S-33S.
43. Taylor GW, Borgnakke WS. Periodontal disease: as-
sociations with diabetes, glycemic control and com-
plications. Oral Dis 2008;14:191-203.
44. Lalla E, Cheng B, Lal S, Tucker S, Greenberg E,
Goland R et al. Periodontal changes in children and
adolescents with diabetes:a case-control study. Dia-
betes Care. 2006;29:295-9.
45. Lopez ME, Colloca ME, Paez RG, Schallmach JN,
Koss MA, Chervonagura A. Salivary characteristics
of diabetic children. Braz Dent J 2003;14:26-31.
46. Farronato G, Salvadori S, Giannini L, Maspero C.
Congenital macroglossia: surgical and orthodontic
management. Prog Orthod 2012;13:92-8.
47. Holtgrave EA, Donath K. Periodontal reactions to
orthodontic forces in the diabetic metabolic state [in
German]. Fortschr Kieferorthop 1989;50:326-37.
48. Real LASV, Ramos AL, Zanoni JN. Modificacoes no
periodonto de ratos diabeticos apos a movimenta-
cao ortodontica. R ��������������������������������
Dental Press Ortodon Ortop Fa-
cial. 2009;14:124-31.
49. Graves DT, Liu R, Alikhani M, Al-Mashat H, Track-
man PC. Diabetes-enhanced inflammation and ap-
optosis—impact on periodontal pathology. J Dent
Res. 2006;85:15-21.
50. Harrison GA, Schultz TA, Schaberg SJ. Deep neck in-
fection complicated by diabetes mellitus. Report of
a case. Oral Surg Oral Med Oral Pathol 1983;55:133-
7.
51. Van der Westhuijzen AJ, Grotepass FW, Wyma G, Pa-
dayachee A. A rapidly fatal palatal ulcer: rhinocere-
bral mucormycosis. Oral Surg Oral Med Oral Pathol
1989;68:32-6.
52. Maia LGM, Monini A, Jacob HB, Gandini Jr LG. Max-
illary ulceration resulting from using a rapid maxil-
lary expander in a diabetic patient. Angle Orthod
2011;81:546-50.
53. Bensch L, Braem M, Van Acker K, Willems G. Or-
thodontic treatment considerations in patients with
diabetes mellitus. Am J Orthod Dentofacial Orthop.
2003;123:74-78.
54. Ship JA. Diabetes and oral health: an overview. J Am
Dent Assoc 2003;134:4S-10S.
55. Mealey BL. The interactions between physicians and
dentists in managing the care of patients with diabe-
tes mellitus. J Am Dent Assoc 2008;139:4S-7S.
56. Reichart PA, Philipsen HP. Color Atlas of Dental
Medicine — Oral Pathology, 1st Edn. Stuttgart/New
York: Thieme; 2000. p. 163.
57. Mitchell L. An introduction to orthodontics. Second
Edition. Oxford: Oxford University Press; 2001. p.
137.
58. Brandt S, Ricketts RM. JCO Interviews Dr. Robert M.
Ricketts on Early Treatment, Part 2. J Clin Orthod
1979;13:115-27.
59. Farronato G, Giannini L, Riva R, Galbiati G, Maspero
C. Correlations between malocclusions and dysla-
lias. Eur J Paediatr Dent 2012;13:13-8.
60. Kneafsey L, Hughes C. Quadhelix appliance thera-
py resulting in pyogenic granuloma of the tongue.
Dent Update 2002;29:462-63.
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
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This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
61. Acharya, Gill, Lloyd. Pyogenic granuloma:a rare side
complication from an orthodontic appliance. J of
Orthod 2011;38:290-3.
62. Crowe MA, Steinberg B. Pediatric pyogenic granu-
loma. Emedicine from WebMD, 2009 [Internet].
Available at: http://emedicine.medscape.com/
article/910112-clinical#a0217 [cited 2009, Oct 13].
63. Neville BW, Damm DD, Allen CM, Bouquot JE. Oral
and maxillofacial pathology. Second edition. St Lou-
is, MO: Saunders Elsevier; 2002. p. 517-9.
64. Svirsky J. Oral Pyogenic Granuloma. Emedicine
from WedMD, 2010 [Internet]. Available at: http://
emedicine.medscape.com/article/1077040 [cited
2009, Oct 13].
65. Giusto TJ. Localized severe periodontitis associated
with retained impression material and root proxim-
® A
ity: report of a case. J N J Dent Assoc 2006;77:39-40.
66. Klein ZD, Shiloah J. Retained silicone impression
material associated with a periodontal abscess. Miss
Dent Assoc J 1999;55:40-1.
T C
67. Greenbaum, Strassler HE. Periodontal complications
following use of the rubber dam:a case report. Op-
erative Dentistry 1994;19:162-4.
H DI
68. Krejci CB. Self-inflicted gingival injury due to ha-
bitual fingernail biting. J Periodontol 2000;71:1029-
31.
69. Regezi JA and Sciubba JJ, Oral Pathology. Sec-
ond Edition. Philadelphia, Pa, USA: WB Saunders;
IG E
1993.
70. Waggoner WF, Ray KD. Bone loss in the permanent
R M
dentition as a result of improper orthodontic elastic
band use: a case report. Quintessence International
1989;20:653-6.
71. Zager NI, Barnett ML. Severe bone loss in a child
initiated by multiple orthodontic rubber bands: case
report. J Periodontol 1974;45:701-4.
P A
72. Zilberman Y, Shteyer A, Azaz B. Iatrogenic exfolia-
tion of teeth by the incorrect use of orthodontic
elastic bands. J Am Dent Assoc 1976;93:89-93.
O V
73. Becker T, Neronov A. Orthodontic elastic separator-
induced periodontal abscess:a case report. Case Rep
Dent 2011;2012:1-3.
C ER
74. Gorelick L, Geiger AM, Gwinnet AJ. Incidence of
white spot formation after bonding and banding.
Y
Am J Orthod 1982;81:93-8.
75. Artun J, Brobakken BO. Prevalence of carious white
spots after orthodontic treatment with multibonded
appliances. Eur J Orthod 1986;8:229-34.
IN
76. O’Reilly MM, Featherstone JDB. Demineralization
and remineralization around orthodontic appli-
ances: an in vivo study. Am J Orthod Dentofacial
Orthop 1987;92:33-40.
77. Geiger AM, Gorelick L, Gwinnett AJ, Griswold PG.
M
The effect of a fluoride program on white spot for-
mation during orthodontic treatment. Am J Orthod
Dentofacial Orthop 1988;94:123-8.
78. Øgaard B. Prevalence of white spot lesions in
19-year-olds:a study on untreated and orthodonti-
cally treated persons 5 years after treatment. Am J
or other proprietary information of the Publisher.
Orthod Dentofacial Orthop 1989;96:423-7.
79. Øgaard B. White spot lesions during orthodontic
treatment: mechanisms and fluoride preventive as-
pects. Semin Orthod 2008;14:183-93.
80. Knosel M, Attin R, Becker K, Attin T. External
bleaching effect on the color and luminosity of in-
active white-spot lesions after fixed orthodontic ap-
pliances. Angle Orthod 2007;77:646-52.
81. Palamara J, Phakey PP, Rachinger WA, Orams HJ. Ul-
trastructure of the intact surface zone of white spot
440 MINERVA STOMATOLOGICA November-December 2013
and brown spot carious lesions in human enamel. J
Oral Pathol 1986;15:28-35.
82. Featherstone JD. The science and practice of caries
prevention. J Am Dent Assoc 2000;131:887-99.
83. Knosel, Bojes, jung, Ziebolz Increased susceptibility
for white spot lesions by surplus orthodontic etch-
ing exceeding bracket base area. Am J of Orthod
Dentofacial Orthop 2012, 141:574-82.
84. Øgaard B, Rolla G, Arends J. Orthodontic appli-
ances and enamel demineralization. Part 1. Lesion
development. Am J Orthod Dentofacial Orthop
1988;94:68-73.
85. Boersma JG, van der Veen MH, Lagerweij MD,
Bokhout B. Caries prevalence measured with QLF
after treatment with fixed orthodontic appliances:
influencing factors. Caries Res 2005;39:41-7.
86. Tufecki, Dixon, Gunsolley, Lindauer. Prevalence
of white spot lesions during orthodontic treatment
with fixed appliances. Angle Orthod 2011;81:206-10.
87. Mizrahi E. Surface distribution of enamel opaci-
ties following orthodontic treatment. Am J Orthod
1983;84:323-31.
88. Bartsch A, Witt E, Sahm G, Schneider S. Correlates
of objective patient compliance with removable
appliance wear. Am J Orthod Dentofacial Orthop
1993;104:378-86.
89. Nanda RS, Kierl MJ. Prediction of cooperation in
orthodontic treatment. Am J Orthod Dentofacial Or-
thop 1992;102:15-21.
90. Preoteasa, Ionescu, Didilescu, Melescanu-Imre,
Bencze, Preoteasa. Undesirable dental hard tissue
effect hypothetically linked to orthodontics-a micro-
scopic study. Rom J Morphol Embryol 2011;52:937-
41.
91. Farronato G, Giannini L, Galbiati G, Maspero C. Sag-
ittal and vertical effects of rapid maxillary expan-
sion in Class I, II, and III occlusions. Angle Orthod
2011;81:298-303.
92. Farronato G, Giannini L, Galbiati G, Consonni D,
Maspero C. Spontaneous eruption of impacted sec-
ond molars. Prog Orthod 2011;12:119-25.
93. Dickers C, Giannini L, Esposito L, Maspero C,
Bellincioni F, Farronato G. Neuromuscolar effects
caused by orthopedic-functional therapy. Mondo
Ortodontico 2009;34:245-53.
94. Farronato G, Giannini L, Galbiati G, Stabilini SA,
Maspero C. Orthodontic-surgical treatment: neuro-
muscular evaluation in open and deep skeletal bite
patients. Prog Orthod 2013;14:41.
95. Farronato G, Giannini L, Galbiati G, Mortellaro C,
Maspero C. Presurgical orthodontic planning: pre-
dictability. J Craniofac Surg 2013;24:e184-6.
96. Giannini L, Maspero C, Batia C, Galbiati G. Valutazi-
one elettromiografica ed elettrognatografica del trat-
tamento ortodontico-chirurgico. Mondo Ortodon-
tico 2011;36:12-28.
97. Maspero C, Giannini L, Riva R, Tavecchia MG, Farro-
nato G. Valutazione del ciclo nasale di dieci giovani
soggetti: indagine rinomanometrica. Mondo Orto-
dontico 2009;5:263-8.
98. Farronato G, Maspero C, Giannini L, Farronato D.
Occlusal splint guides for presurgical orthodontic
treatment. J Clin Orthod 2008;42:508-12.
Conflicts of interest.—The authors certify that there is
no conflict of interest with any financial organization re-
garding the material discussed in the manuscript.
Received on October 25, 2013.
Accepted for publication on October 31, 2013.
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
ORAL TISSUES AND ORTHODONTIC TREATMENT FARRONATO
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Tessuti orali e trattamento ortodontico: effetti avversi più comuni
I l progresso della medicina, che ha portato ad un
aumento dell’aspettativa di vita, è risultato in un
aumento della richiesta di cure odontoiatriche 1. Per
questo motivo, alla base di una corretta terapia oc-
corre disporre dell’aspetto psicosociale di ciascun
paziente, al fine di conoscere i fattori stressanti le-
gati alle sue aspettative, motivazioni e necessità 2. È
quindi importante dare la possibilità al paziente di
capire i limiti della terapia, informandolo sui van-
taggi e specialmente sugli svantaggi del trattamento
programmato 3.
® A
In particolare, l’ortodontista deve essere coscien-
te di tutte le possibili implicazioni cliniche di tale
trattamento. Egli infatti, incontrando i suoi pazienti
T C
ad intervalli di 6-8 settimane, ha la possibilità di
intercettare precocemente l’insorgenza di eventuali
complicanze conseguenti alla terapia. Una completa
H DI
anamnesi medica e odontoiatrica dovrebbe essere
eseguita e regolarmente aggiornata.
Il trattamento ortodontico ha lo scopo di miglio-
rare la salute orale, l’estetica e la funzione. Oltre ai
IG E
risultati attesi, però, possono verificarsi effetti colla-
terali non previsti.
R M
Cambiamenti delle condizioni locali, ipotetica-
mente correlati al trattamento ortodontico, possono
risultare in effetti negativi sui tessuti, la presenza dei
quali può interferire con i tempi di prognosi e con
la qualità della terapia, a breve e a lungo termine 4.
P A
L’obiettivo di tale articolo è di fornire una revisio-
ne della letteratura circa le problematiche che pos-
O V
sono presentarsi in corso di trattamento ortodonti-
co, illustrando inoltre alcune patologie associate ad
anomalie scheletriche e dentali, e dunque di rilievo
C ER
nella pratica ortodontica.
Y
Materiali e metodi
IN
La revisione sistematica della letteratura è stata
condotta attraverso l’utilizzo della banca dati Pub-
Med. Le parole chiave inserite sono “oral patholo-
gies after orthodontic treatment” (209 articoli) e “or-
M
thodontic treatment oral pathologies” (535 articoli).
Sono stati considerati solo gli articoli che fornisse-
ro informazioni riguardanti le dirette conseguenze
del posizionamento di un apparecchio ortodontico
giungendo alla trattazione dei seguenti argomenti:
—  Le infezioni da candida;
or other proprietary information of the Publisher.
—  Gli effetti sui tessuti molli;
—  Gli effetti sui tessuti parodontali;
—  Gli effetti sui tessuti duri.
Risultati
Suddividiamo ora le problematiche emerse dal-
la nostra revisione sistematica della letteratura, che
possono insorgere dal trattamento ortodontico e
Vol. 62 - No. 11-12 MINERVA STOMATOLOGICA 441
che possono quindi inficiare la buona riuscita dello
stesso.
Infezioni da candida
La Candida è un patogeno opportunista presente
in circa il 50-60% della popolazione umana.5
Numerosi studi dimostrano la relazione tra la
presenza del microrganismo e la prevalenza di ca-
rie6 e di problematiche parodontali7.
La colonizzazione orale varia da individuo a in-
dividuo e a seconda della posizione geografica; il
micete è stato isolato da placca dentale, da tessuti
dentali duri e dalla flora sub-gengivale8
Prevalenza di portatori candida
In una revisione di 41 studi di Odds 9, le quat-
tro più alte frequenze riscontrate sono state: 71% e
54%, rispettivamente, tra gli scolari e i neonati nel
Regno Unito, il 56% tra i bambini israeliani e il 69%
del personale infermieristico in Germania.
É stato riportato che la presenza di un appa-
recchio ortodontico fisso (Fixed Orthodontic Ap-
pliances: FOA) così come di protesi totali o parziali
rimovibili predispone ad un aumento del tasso di
microbi e di infezioni conseguenti 10. Così, Truchot
(1991) ha dimostrato un legame tra un aumento del
livello di placca nei soggetti trattati con FOAs e lo
sviluppo conseguente di gengivite 11. Questi sogget-
ti sono anche più inclini alla malattia parodontale 12,
alla perdita di sostegno parodontale 13 e alle lesioni
cariose su entrambe le superfici vestibolare e lin-
guale dei denti 14.
Hagg et al.15 hanno effettuato uno studio per
valutare delle significative alterazioni quantitative
e qualitative del tasso di Candida e Enterobacteri-
aceae e le variazioni associate nell’indice di placca
in una popolazione cinese adolescente con il cavo
orale sano prima e durante la terapia FOA. Tutti gli
individui hanno ricevuto istruzioni di igiene orale
e dell’uso del filo interdentale. Gli indici di plac-
ca sono stati registrati come indicatori dello stato
del cavo orale in base ai criteri di Silness e Loe
(1964). Il tasso di candida è stato valutato utilizzan-
do tre diverse tecniche standardizzate: la metodica
di coltura, gli sciacqui orali e il metodo di raccolta
di placca. Il primo è stato utilizzato per determinare
la colonizzazione da parte del microrganismo del-
la mucosa orale, il secondo per la quantificazione
della specie Candida ed Enterobacteriaceae e il ter-
zo per identificare le specie presenti nei campioni.
Questo studio riporta un iniziale indice di placca e
di carica batterica totale bassi per il gruppo di pa-
zienti al baseline, ma dopo l’inizio della FOA, si è
notato un aumento medio dell’indice di placca del
10%. E ‘ stato inoltre dimostrato che la presenza di
candida aumenta in modo significativo (27%) dopo
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO ORAL TISSUES AND ORTHODONTIC TREATMENT
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
l’inserimento degli apparecchi fissi, rilevazione ese-
guita con la tecnica della coltura.
Tali modifiche nell’accumulo di placca durante
il trattamento ortodontico con apparecchi removi-
bili 16, 17 e fissi 18, 19 sono state riportate da diversi
autori.
In particolare, Addy et al.17 hanno presentato
uno studio a lungo termine su pazienti trattati con
apparecchi rimovibili. La percentuale dei carrier
della candida prima del trattamento era del 39%,
dopo 9 mesi, era aumentata al 79% e dopo il tratta-
mento si era ridotta al 14%. Tredici dei 33 pazienti
sono risultati convertiti da non portatori a portato-
ri durante la terapia, ma dieci pazienti di questi si
® A
sono riconvertiti a non portatori dopo la rimozione
degli apparecchi.
In un recente studio comprendente 112 pazienti
T C
ortodontici trattati con apparecchi fissi, il 32% pre-
sentava il microrganismo prima del trattamento, tale
H DI
percentuale è aumentata gradualmente al 50% al
quinto mese ed è rimasta a quel livello per il resto
del periodo di osservazione, similmente a quanto
riportato nello studio presentato da Arslan et al.,20, 21
che però non erano in grado di riferire il numero
IG E
di non-portatori convertiti in portatori dopo l’inseri-
mento di apparecchi fissi.
R M
Tuttavia, nello studio condotto da Lee et al.,22
l’aumento della frequenza dei portatori di Candida
non era significativo.
In contrasto, Sinclair et al.23 non hanno mostrato
P A
differenze significative tra la fase di pre-trattamento
e la fase di terapia con FOA in 13 adolescenti, sup-
portato da Davies et al.24 Essi hanno dimostrato una
O V
riduzione significativa di tutti gli indici gengivali e
di placca tra il baseline e la valutazione a 3 anni in
entrambi i gruppi trattati ortodonticamente e non
C ER
trattati.
Y
Siti di prevalenza
Gli apparecchi rimovibili proteggono i microrga-
IN
nismi dalla rimozione naturale e meccanica della
saliva, mentre gli apparecchi fissi non coprono la
mucosa quindi, come atteso, la distribuzione della
candida in questo caso sarà simile a quella dei sog-
M
getti che non indossano apparecchi 20.
Il sito più frequente di isolamento della candida
nei soggetti non portatori di apparecchi e pazienti
FOA è stata la parte posteriore della lingua (16,17),
mentre per i portatori di apparecchi mobili è stato
il palato (17). Dopo la rimozione dell’apparecchio
or other proprietary information of the Publisher.
ortodontico, la prevalenza di candida è tornata a
livelli non significativamente diversi da quelli pre-
cedenti al trattamento. (20)
Prevalenza delle diverse specie di Candida
La specie più frequentemente isolata è sicura-
mente la candida albicans 15, 24, 26. Risultati simili
sono stati riportati da Arslan et al, nella cui ricerca
effettuata su adolescenti del sud-est della Turchia
442 MINERVA STOMATOLOGICA November-December 2013
la C. albicans è la specie maggiormente ritrovata
(73,8%), seguita da C. tropicalis, C. krusei, C. kefyr
(7,14%) e C. parapsiloris (4,76%) 8.
L’effetto degli apparecchi sull’igiene orale
Si è dimostrato che l’inserimento di un apparec-
chio ortodontico nella cavità orale, aumenta il nu-
mero di zone di ritenzione della placca 27, 28.
Addy et al.16 hanno dimostrato che gli indici totali
di placca per i portatori di apparecchi mobili e non
portatori non erano significativamente differenti.
Per i portatori di apparecchi rimovibili, tuttavia,
gli indici di placca palatali erano significativamente
aumentati, mentre l’indice vestibolare era diminu-
ito rispetto alle corrispondenti superfici nei non-
portatori 20. Può essere che l’apparecchio rimovibile
protegga la placca dalla rimozione naturale e mec-
canica. Un effetto simile, ma ridotto è stato notato
da Arendorf e Addy 17. Hagg et al.15 hanno anche
osservato un aumento del 10% dell’indice di placca
dopo l’inserimento di un apparecchio fisso. Questo
potrebbe essere causato dalla presenza di bande e
brackets ortodontici, e quindi della maggiore dif-
ficoltà di spazzolamento delle superfici dentali. In
uno studio con un follow-up a lungo termine di
Arslan ed altri, le quote di candida in pazienti sotto-
posti a trattamento ortodontico con apparecchi fis-
si aumenta gradualmente nei successivi controlli a
scadenza mensile. Gli incrementi nella conta di tali
microrganismi nella saliva, e in corrispondenza del
mascellare superiore e della mandibola sono stati-
sticamente significativi, escludendo il confronto del
6 ° e del 12 ° mese8.
Tuttavia, alcuni studi hanno dimostrato che non
vi è alcuna differenza significativa nell’accumulo di
placca tra pre-trattamento e fase di terapia fissa 23, 24:
la capacità di mantenere una buona igiene orale po-
trebbe essere il fattore più importante. Uno studio
condotto a Hong Kong 29 ha concluso che la pre-
senza di un apparecchio può impedire al paziente
di mantenere una buona igiene orale indipendente-
mente dal fattore comportamentale. Tuttavia, non vi
è alcuna prova diretta a dimostrare che una scarsa
igiene orale conduca alla colonizzazione della can-
dida come non tutti gli studi mostrano che l’inse-
rimento di apparecchi porta ad un aumento della
placca, ma vi è comunque un aumento della densità
di candida.
Per quanto riguarda i materiali, Brusca et al.30
hanno scoperto che la maggiore adesione di Can-
dida albicans avviene nei confronti dei brackets
in composito, seguita da quelli in ceramica e suc-
cessivamente i metallici. Questo accade perché il
microrganismo trova una nicchia ecologica molto
favorevole nella struttura più porosa e meno li-
scia del materiale di supporto. Come questa diffe-
renza nella adesione ai diversi materiali influenzi
il tasso e la densità della candida non è stato
studiato.
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
ORAL TISSUES AND ORTHODONTIC TREATMENT FARRONATO
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
Colonizzazione da Candida e candidosi
La specie Candida Albicans si trova spesso nel
cavo orale dell’uomo, ma solo pochi dei portatori
sviluppano segni clinici di candidosi. La candidosi
orale risulta dalla crescita del microrganismo e dal-
la penetrazione nei tessuti orali. Il fattore più im-
portante che definisce lo stato di assenza, coloniz-
zazione o candidosi è la competenza immunitaria
dell’ospite 20.
Cannon et al.31 hanno scoperto che senza l’ade-
sione, non si verifica il mantenimento dell’adeguato
tasso di crescita all’interno cavo orale. La progressio-
ne ad un’infezione della mucosa dipende dall’ade-
® A
renza e dal tasso di crescita, ma coinvolge anche
la penetrazione nei tessuti. Affinché un’infezione
persista, il sistema immunitario deve fallire nel cer-
T C
care di contenere la crescita dei miceti. L’equilibrio
tra l’assenza, la colonizzazione libera o la candidosi
dipende quindi dalla capacità dei ceppi di Candida
H DI
di modulare l’espressione dei fattori di virulenza in
risposta a cambiamenti ambientali, combinata con
la competenza del sistema immunitario dell’ospi-
te. I fattori dell’ospite che sono stati associati ad
IG E
un aumento del tasso di Candida sono: xerosto-
mia 32, pH salivare basso 33, il fumo 33, l’aumento
R M
della concentrazione di glucosio nella saliva 34, l’età
avanzata 35, 36. La prevalenza delle specie di Candi-
da è maggiore nei pazienti immunocompromessi 37
(AIDS, neoplasie, trattamenti con antitumorali e/o
antibiotici a lungo termine) nel cavo orale dei quali
P A
si può avere una crescita eccessiva di C. albicans
eliminando i microrganismi concorrenti.
O V
Tessuti molli
C ER
Ulcerazione mascellare e diabete
Y
L’iperglicemia modifica l’equilibrio metabolico,
promuovendo alcune modifiche nei tessuti vasco-
IN
lari, una ridotta efficienza dei neutrofili 38, un’au-
mentata distruzione del tessuto connettivo e osseo
e un’esacerbazione dei mediatori infiammatori 38-42.
In bocca questi fattori determinano la progressione
M
e l’incremento della severità della malattia parodon-
tale 41, 43. Nella fase iniziale vi è predominanza di
gengivite e parodontite, con la possibile evoluzione
a malattia parodontale avanzata 41, 42, 44. Le principali
modifiche trovate nella saliva sono la ridotta produ-
zione e l’alterazione della composizione, che sono
or other proprietary information of the Publisher.
correlate all’incremento di glucosio, degli zucche-
ri, delle proteine e dei livelli di α-amilasi 45, fattori
che possono causare ulcere, cheilite e fessurazioni
linguali 40, 46. La maggior quantità di glucosio nella
saliva e nel fluido crevicolare gengivale stimola la
crescita batterica, riduce la capacità dei fibroblasti di
promuovere la guarigione e aumenta la produzione
di acido lattico. Il DM di tipo 1 provoca un ritar-
do nella rigenerazione ossea, l’indebolimento del
legamento parodontale, microangiopatie nella zona
Vol. 62 - No. 11-12 MINERVA STOMATOLOGICA 443
gengivale 47,48. La ridotta capacità di formazione os-
sea è dovuta all’apoptosi delle cellule fibroblastiche
e osteoblastiche in soggetti diabetici 49.
Sono stati pubblicati alcuni case report sul peri-
colo di vita dovuto sia a infezioni profonde a dipar-
tenza da un ascesso parodontale 50, sia a ulcerazioni
mascellari in pazienti con diabete mellito (non si
tratta di ulcere superficiali, ma di malattie granulo-
matose profonde) 51.
Maia et al.52 hanno dimostrato la reazione all’uso
di un espansore mascellare rapido in un pazien-
te di 9 anni. Quattro giorni dopo la cementazione
dell’RME, il bambino alla rivalutazione lamenta di-
sagio mascellare, sanguinamento e dolore continuo
localizzato. L’esame clinico rivela la presenza di
un’ulcerazione necrotica, di un’area emorragica dal
primo molare permanente al primo molare deciduo,
infiammazione estesa del palato. L’apparecchio vie-
ne rimosso e il bambino monitorato ogni 3 giorni
per valutare la regressione dell’ulcera. Il paziente è
sottoposto ad accertamenti medici e che hanno mo-
strato che era affetto da diabete mellito tipo 1 (DM).
Quindi il cavo orale può mostrare i primi segni o
sintomi di una patologia diabetica non diagnosticata
o scarsamente controllata 40, 53-55. Il controllo glice-
mico nella gestione del DM, è la chiave per ridurre
l’impatto delle infezioni acute orali e le complicanze
micro vascolari 40, 41 e, per i pazienti diabetici sotto
buon controllo medico, tutte le procedure dentali
possono essere eseguite 38, 40, 42, 53.
Granuloma piogenico
Un granuloma piogenico è un “particolare tipo
di iperplasia infiammatoria” 56 che nasce come ef-
fetto collaterale associato all’uso dell’apparecchio
ortodontico quad helix. Si tratta di un dispositivo
fisso che consente l’espansione differenziale ante-
riore e posteriore 57 ed è stato descritto da Ricketts
nel 1979 58. I rischi connessi all’uso di tali appa-
recchiature sono rischi a breve termine (linguaggio
alterato 59, irritazione dei tessuti molli o ulcerazioni
più comunemente coinvolgenti la lingua e males-
sere generale) o a lungo termine (gengiviti in cor-
rispondenza dei denti molari, carie, riassorbimento
radicolare e gravissimo tipping dentale). Solo pochi
autori hanno fatto studi su questa rara complicanza.
Nel 2002 Kneafsey et al. hanno riportato la risolu-
zione spontanea di un granuloma piogenico in via
di sviluppo con la sola rimozione del quad helix. La
lesione aveva delle dimensioni di circa 1x6mm e si
era sviluppata in un periodo di 6 mesi circa 60.
Nel caso descritto da Acharya nel 2011 61 la le-
sione aveva dimensioni quasi doppie (1 cm ^ 2) e
si era sviluppata in un periodo di 4 mesi circa. Era
situata nel lato posteriore sinistro della lingua e la
sua superficie mostrava la chiara rientranza causata
dal quad helix con ulcerazione e cheratosi / accu-
mulo di placca associati. Il trattamento è consisti-
to in resezione chirurgica della massa, seguito da
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO ORAL TISSUES AND ORTHODONTIC TREATMENT
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
una conferma istologica. Esso è stato supportato da
istruzioni di igiene orale e dalla rimozione dell’ap-
parecchio.
Le lesioni di solito appaiono come masse pedun-
colate lisce o lobulate, con superfici ruvide e ulce-
rate. Le loro dimensioni variano da pochi millimetri
a diversi centimetri di diametro. Clinicamente sono
in genere indolore e spesso sanguinano facilmen-
te 62, 63. Il sito di manifestazione più frequente è la
gengiva vestibolare nella parte anteriore del ma-
scellare superiore 56, 63, seguita da labbra, superficie
dorsale della lingua e mucosa vestibolare 56, 63, 64. Le
donne di età compresa tra i 11-40 anni sono par-
ticolarmente a rischio di sviluppare tali lesioni a
® A
causa di influenze ormonali 56, 63. Una forma comu-
nemente nota è l’epulide gravidica63, che può veri-
ficarsi durante la gravidanza e la cui manifestazione
T C
è promossa da elevati livelli circolanti di estrogeni
e progesterone.
H DI
Effetti parodontali
La parodontite localizzata e gli ascessi parodon-
IG E
tali possono essere associati ad una varietà di ma-
teriali dentari, come il silicone da impronta (come
R M
dimostrato da Giusto et al.) 65, 66, la diga di gomma
(Greenbaum et al.) 67, e anche ad auto-lesioni gen-
givali a causa dell’abitudine di onicofagia (Krejci et
al.) 68.
Parecchi millimetri di attacco parodontale e os-
P A
seo possono essere persi in non più di qualche
giorno. L’esordio è improvviso e accompagnato da
O V
una risposta infiammatoria acuta; può verificarsi un
gonfiore gengivale doloroso intorno ai denti colpiti
e, a seconda della gravità dell’infezione, il paziente
C ER
può sperimentare linfadenite regionale, malessere
o febbre 69.
Y
Waggoner et al.70 hanno riportato come un ela-
stico separatore che scivola sotto gengiva, se non
rilevato immediatamente, potrebbe spostarsi lungo
IN
le radici, con conseguente significativa perdita di
osso alveolare. Altri autori hanno supportato questi
risultati, come Zager e Barnett 71, che nel 1974 han-
no riportato un caso di perdita ossea causata da più
M
elastici separatori, e Zilberman et al.72, che hanno
mostrato un caso di esfoliazione iatrogena dei denti
a causa di un uso non corretto di tali dispositivi.
Anche Becker et al.73 hanno messo in evidenza
i rischi potenziali in un paziente sano la cui pre-
parazione al trattamento ortodontico consisteva dei
or other proprietary information of the Publisher.
suddetti elastici. Ha presentato gonfiore, accompa-
gnato da ulcere bianche. L’indagine radiografica ha
rivelato la dislocazione dell’elastico separatore, che
è stato rimosso mediante curettage parodontale.
Tessuti duri: white spot lesions (WLS) e carie
Il condizionamento della superficie dello smalto
mediante acido fosforico per ottenere microriten-
444 MINERVA STOMATOLOGICA November-December 2013
zione e il fissaggio dei brackets mediante i sistemi
adesivi compositi sono componenti comuni della
terapia ortodontica fissa. La demineralizzazione del-
lo smalto è un significativo rischio associato quan-
do l’igiene orale è scarsa. La prevenzione di questi
danni è una delle più grandi sfide affrontate dai
clinici: lo sviluppo di lesioni cosiddette white spot
è attribuita al prolungato accumulo di placca intor-
no agli attacchi 74-78. Non solo gli apparecchi fissi
rendono le convenzionali procedure di igiene ora-
le più difficili, ma aumentano altresì il numero di
siti di ritenzione di placca sulle superfici dei denti
che sono normalmente meno suscettibili di svilup-
po di carie 79. Tali lesioni non sono solo estetica-
mente sgradevoli soprattutto sui denti anteriori 80,
ma rappresentano anche una prima fase di carie,
conducendo ad una mineralizzazione significativa-
mente ridotta degli strati esterni dello smalto 81, che
potranno progredire ad uno stato in cui il ripristino
sarà necessario, se l’inadeguatezza dell’igiene orale
prevale 82. Precedenti esperimenti su smalto bovi-
no hanno suggerito che le WLS potrebbero essere
innescate iatrogenicamente in alcune circostanze
come di surplus di mordenzatura di zone di smalto
che non vengono successivamente coperte da bra-
ckets o materiale adesivo. Questo può essere parti-
colarmente grave nei denti in cui quasi l’intera su-
perficie dello smalto vestibolare viene condizionata
ma successivamente non completamente coperta
dai suddetti sigillanti 83. Le WLSs possono diventare
evidenti intorno agli attacchi entro 1 mese (come
riportato da Ogaard et al.) dal loro posizionamento,
anche se la formazione di carie propriamente dette
richiede solitamente almeno 6 mesi 84.
Prevalenza
Una revisione della letteratura disponibile sulla
prevalenza della WLS ha dimostrato che alcuni studi
segnalano la presenza di queste lesioni al completa-
mento del trattamento ortodontico.
A seconda della tecnica di valutazione utilizzata,
la prevalenza varia.
Gorelick et al.,74 utilizzando la tecnica dell’esame
visivo, hanno riportato che il 50% dei pazienti aveva
una o più WLSs alla fine del trattamento.
Boersma et al.85, mediante la metodica della mi-
croscopia a fluorescenza, hanno riferito una percen-
tuale del 97%.
La diagnosi precoce di WLSs è di grande impor-
tanza, in quanto consentirebbe agli odontoiatri di
attuare misure di prevenzione.
Tufekci et al.86 hanno riportato nel loro studio
che il 38% dei soggetti ha avuto un WLS clinica-
mente visibile a 6 mesi dall’inizio del trattamento,
questo numero è aumentato al 46% alla valutazione
fatta a 12 mesi. Solo l’11% del gruppo di controllo
presentava almeno una lesione a macchia bianca.
Una maggiore prevalenza nello studio di Gorelick et
al. può essere attribuito alla inclusione di denti sia
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
ORAL TISSUES AND ORTHODONTIC TREATMENT FARRONATO
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
mascellari sia mandibolari, e alla maggiore durata
del trattamento ortodontico (circa 24 mesi), contro
l’esame dei soli denti mascellari da canino a canino
a 6 e 12 mesi dall’inizio del trattamento ortodontico
nello studio di Tufecki et al.
Distribuzione sui differenti elementi dentali e tra
maschi e femmine:
In letteratura, notizie contrastanti hanno descritto
la distribuzione di WLSs: Gorelick et al74 hanno ri-
ferito che i denti più comunemente colpiti sono gli
incisivi laterali mascellari. Mizrahi 87 ha concluso, in-
vece, che sono i primi molari mascellari e mandibo-
® A
lari. Ogaard 78 si trova d’accordo con le conclusioni
di Mizrahi. Al contrario, Geiger et al.77 hanno riferito
T C
che le lesioni si verificano più frequentemente sugli
incisivi laterali superiori e canini. Tufekci et al.86,
tuttavia, non hanno trovato differenze significative
H DI
tra i denti a 6 mesi, a 12 mesi, o al giorno del ban-
daggio (considerato come controllo).
Un altro dato interessante è la differenza enorme
tra la prevalenza delle WSL nei maschi e nelle fem-
IG E
mine. Nello studio Tufekci et al.86, tra soggetti che
hanno avuto almeno una lesione, il 76% era di sesso
R M
maschile. Questi risultati differiscono da quelli otte-
nuti da Gorelick 74, i quali mostrano che l’incidenza
è del 44% per i maschi e 54% per le ragazze. Tutta-
via uno studio più recente di Boersma 85 ha trovato
che il 40% delle superfici vestibolari nei maschi pre-
P A
sentava delle demineralizzazioni rispetto al 22% nel-
le femmine. Quindi, una possibile spiegazione per
O V
questi risultati è che le femmine sono generalmente
pazienti maggiormente compliant 88, 89.
Un’analisi microscopica fatta da Teodora Preo-
C ER
teasa et al.90 (eseguita utilizzando lo stereo-micro-
scopio ad alta precisione su nove denti estratti), ha
Y
rivelato la presenza di cambiamenti sia sulla super-
ficie vestibolare della corona di premolari superiori
con una storia di trattamento ortodontico, nell’area
IN
in cui era stato posizionato il bracket, sia nella parte
apicale della radice, come effetto indiretto del mo-
vimento dentale.
In termini di colore è stato riscontrato un aspetto
M
irregolare con una chiara identificazione della zona
in cui è stata applicato l’attacco: l’area dello smalto
corrispondente alla base del dispositivo ortodon-
tico ha presentato un aspetto biancastro piuttosto
uniforme, mentre l’area corrispondente ai margini
del bracket è stata valutata come avente delle al-
or other proprietary information of the Publisher.
terazioni nel colore (aspetti più chiari e più scuri).
Inoltre, la corrispondente superficie dello smalto è
stata valutata come avente una rugosità superficiale
superiore alle adiacenti superfici vestibolari e lin-
guale (usate come controllo). Per quanto riguarda la
parte apicale della radice, tutti i denti con una storia
di trattamento ortodontico presentano un contorno
molto irregolare, con interruzione della continuità
della struttura dentale dura. Sono state identifica-
te lacune multiple con differenti profondità, ap-
Vol. 62 - No. 11-12 MINERVA STOMATOLOGICA 445
parenze generali che fanno pensare alla presenza
di riassorbimento radicolare apicale. In contrasto,
l’aspetto della superficie della radice dei denti ap-
partenenti al gruppo di controllo era molto diverso:
si è valutato come uniforme, con una forma della
radice lineare, non essendo identificate lacune di
riassorbimento.
I principali risultati dello studio di Knösel et al.83
rivelano che la formazione di white spot lesions di-
pende anche dalla durata della mordenzatura pre-
cedente al posizionamento del bracket. Una durata
di mordenzatura superiore a 15 secondi ha un effet-
to chiaramente significativo sulla formazione della
lesione e sulla progressione, soprattutto se non vie-
ne eseguito un’adeguato spazzolamento del dente.
Precedenti ricerche hanno indicato che la durata di
15 secondi è sufficiente per ottenere un’adatta forza
di adesione per scopi ortodontici.
Discussione e conclusioni
La presente revisione della letteratura dimostra
che il trattamento ortodontico può avere conse-
guenze a carico del legamento parodontale, dei
tessuti molli e duri, provocando altresì infezioni da
candida.
— Per quanto riguarda quest’ultima problemati-
ca la maggior parte degli autori ritiene che la pre-
senza di apparecchiature sia fisse che mobili au-
menti la prevalenza di portatori di candida, nello
specifico è la specie Candida Albicans quella mag-
giormente isolata. I siti maggiormente colpiti sono
la parte posteriore della lingua nei soggetti non trat-
tati e nei pazienti FOA, mentre nei soggetti portatori
di apparecchi mobili la sede prevalentemente espo-
sta è il palato. Dopo la rimozione dei dispositivi,
comunque, la prevalenza torna ai livelli precedenti
al trattamento. Anche dimostrando la presenza del
microrganismo all’interno del cavo orale, non è det-
to che il soggetto sviluppi candidosi. Questo per-
ché l’equilibrio tra assenza del microrganismo, la
colonizzazione e lo stato di candidosi dipende sia
dalla virulenza del micete, sia dalla competenza del
sistema immunitario dell’ospite.
—  A carico dei tessuti molli sono state riscon-
trate ulcerazioni a carico del mascellare superiore
dovute al trattamento con espansore rapido del pa-
lato91 in pazienti affetti da diabete mellito tipo 1.
L’iperglicemia dovuta a tale patologia altera l’equili-
brio metabolico portando a delle modificazioni tis-
sutali responsabili di tali lesioni. Un’altra rara com-
plicanza presa in esame è il granuloma piogenico in
seguito al posizionamento di un apparecchio quad
helix. Esso è più frequente a carico della gengiva
vestibolare con dimensioni che variano da pochi
millimetri a diversi centimetri di diametro.
—  Gli elastici separatori ortodontici, così come
altri dispositivi odontoiatrici possono provocare
problemi a livello parodontale. Sono stati pubblicati
not permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo,
means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use is
FARRONATO ORAL TISSUES AND ORTHODONTIC TREATMENT
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
casi di perdita di attacco osseo a causa di elastici
dislocati sotto-gengiva, ma anche casi ben più gravi
di esfoliazione iatrogena del dente. Fondamentale
risulta quindi la corretta indagine radiografica per
intercettare in tempo tale tipo di problematica.
—  La demineralizzazione dello smalto è un ri-
schio comune dovuto all’incorretto condiziona-
mento della superficie del dente con mordenzanti
e sistemi adesivi per il fissaggio degli attacchi or-
todontici. Lo sviluppo delle cosiddette white spot
lesion è legato al prolungato accumulo di placca
attorno ai brackets. Di qui l’importanza di una cor-
retta igiene orale, per evitare la manifestazione di
tali lesioni che rappresentano un primo stadio di
® A
carie. Le WSL diventano visibili ad un mese dal ban-
daggio, mentre lo sviluppo di carie richiede solita-
mente 6 mesi. È stato riferito da diversi studi come
T C
un’eccessiva durata della mordenzatura, specie se
non completamente ricoperta da sealers e adesivi
H DI
compositi, possa portare alla comparsa di queste
sgradevoli conseguenze.
È quindi importante che l’ortodontista sappia
intercettare tutte queste complicanze che possono
inficiare la buona riuscita del trattamento ortodon-
IG E
tico 92-98, richiedendo nella peggiore delle ipotesi
l’interruzione della terapia prima del suo comple-
R M
tamento.
Riassunto
P A
O V
Obiettivo del presente lavoro è stato quello di
fornire una revisione della letteratura circa le pro-
C ER
Y
IN
M
or other proprietary information of the Publisher.
446 MINERVA STOMATOLOGICA November-December 2013
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blematiche che possono presentarsi durante il trat-
tamento ortodontico. Attraverso l’utilizzo della ban-
ca dati PubMed sono stati raccolti degli articoli che
fornissero informazioni riguardanti le dirette con-
seguenze del posizionamento di un apparecchio
ortodontico, giungendo alla trattazione dei seguen-
ti argomenti: le infezioni da candida, gli effetti sui
tessuti molli, gli effetti sui tessuti parodontali e gli
effetti sui tessuti duri. La presenza nel cavo orale di
apparecchi aumenta la prevalenza dei portatori di
candida, nello specifico la specie Candida Albicans
è quella più frequentemente isolata. L’equilibrio tra
assenza del microrganismo, la colonizzazione e lo
stato di candidosi dipende sia dalla virulenza del
micete, sia dalla competenza del sistema immunita-
rio dell’ospite. A carico dei tessuti molli sono stati ri-
scontrati casi di ulcerazione mascellare da espanso-
re rapido del palato e granuloma piogenico dovuto
a quad helix, quest’ultimo maggiormente osservato
a carico della gengiva vestibolare. La prima eve-
nienza è stata riscontrata, invece, in pazienti affetti
da diabete mellito di tipo 1 a causa delle modifica-
zioni tissutali indotte da tale condizione patologica.
Gli effetti parodontali più gravi sono causati da un
uso incorretto di elastici separatori ortodontici. In-
fine le White spot lesions sono le infauste conse-
guenze di un errato condizionamento dello smalto
all’atto di fissaggio del bracket. Esse rappresentano
un primo stadio di carie nell’area di posizionamento
del bracket. L’ortodontista è tenuto ad intercettare
tali problematiche per non inficiare la buona riusci-
ta del trattamento.
Parole chiave: Effetti collaterali - Ortodonzia - Pa-
tologie orali.