Original Article

Effect of orthodontic treatment on periodontal health of periodontally

compromised patients:
A randomized controlled clinical trial
Meenu Gehlota; Rekha Sharmab; Shikha Tewaric; Davender Kumard; Ambika Guptae

ABSTRACT
Objectives: To evaluate the effect of fixed orthodontic treatment on periodontal parameters in
periodontally compromised adult orthodontic patients.
Materials and Methods: This was a prospective, randomized, controlled clinical trial. Thirty-six
periodontally compromised adult patients (mean age: 29.67 6 4.8 years) were randomly allocated
to either test (perio-ortho) or control group (perio). After periodontal stabilization in both groups,
orthodontic treatment was started in the test group, whereas the control group remained on
periodontal maintenance only. Evaluation and comparison of clinical parameters (plaque index [PI];
gingival index [GI]; bleeding on probing [BOP]; probing depth [PD]; clinical attachment level [CAL])
of both groups was assessed at three time intervals: T0 (base line), T1 (at start of orthodontic
treatment), and T2 (1 year after start of orthodontic treatment). Radiological parameters (alveolar
bone levels [ABL]) were recorded using CBCT at T1 and T2.
Results: Intragroup analysis showed statistically significant improvement in all clinical and
radiological periodontal parameters in both groups (P  .05). Intergroup comparison revealed
improvement in the periodontal parameters was not statistically significant between the groups (P 
.05). Subgroup analysis showed reduction in the number of moderate and severe periodontitis sites
in both groups with significant more gains in ABL in the test group compared to the control group.
Conclusions: Orthodontic treatment after periodontal stabilization does not have any detrimental
effect on periodontal health in adult periodontally compromised orthodontic patients and may add to
the benefits achieved by periodontal treatment alone. (Angle Orthod. 2022;92:324–332.)
KEY WORDS: Periodontitis; Orthodontic treatment; Cone-beam computed tomography; Clinical
attachment level

INTRODUCTION focus of society on esthetics and health conscious-

ness. With the incidence of periodontal problems
An increasing number of adult patients are now shown to increase with age, ortho-perio interactions
seeking orthodontic treatment due to an increased play an important role in management of these

a
Postgraduate Student, Department of Orthodontics and Dentofacial Orthopedics, Post Graduate Institute of Dental Sciences, Pt. B.
D. Sharma University of Health Sciences, Rohtak, India.
b
Senior Professor & Head, Department of Orthodontics and Dentofacial Orthopedics, Post Graduate Institute of Dental Sciences, Pt.
B. D. Sharma University of Health Sciences, Rohtak, India.
c
Professor, Department of Periodontics and Oral Implantology, Post Graduate Institute of Dental Sciences, Pt. B. D. Sharma
University of Health Sciences, Rohtak, India.
d
Associate Professor, Department of Orthodontics and Dentofacial Orthopedics, Post Graduate Institute of Dental Sciences, Pt. B. D.
Sharma University of Health Sciences, Rohtak, India.
e
Senior Professor and Head, Department of Oral Medicine and Radiology, Post Graduate Institute of Dental Sciences, Pt. B. D.
Sharma University of Health Sciences, Rohtak, India.
Corresponding author: Dr Shikha Tewari, Professor, Department of Periodontics and Oral Implantology, Post Graduate Institute of
Dental Sciences, Pt. B. D. Sharma University of Health Sciences, Rohtak, Haryana, India
(e-mail: drshikhatewari@yahoo.com)
Accepted: October 2021. Submitted: February 2021.
Published Online: December 9, 2021
Ó 2022 by The EH Angle Education and Research Foundation, Inc.

Angle Orthodontist, Vol 92, No 3, 2022 324 DOI: 10.2319/022521-156.1

ORTHO-PERIO MANAGEMENT
patients.1 Orthodontic problems in the majority of these
adult patients are a consequence of their underlying
periodontal issues leading to reduced periodontal
support and resulting in pathological migration, procli-
nation of maxillary anterior teeth, interdental spacing,
rotation and overeruption, resulting in compromised
function and esthetics.2 Unfortunately there is no
evidence-based solution to these problems and, with
an increasing number of adults with malocclusion and
compromised periodontium seeking orthodontic treat-
ment, it is important to clarify the various issues
involved in managing periodontally compromised
dentitions. Orthodontic treatment in periodontally in-
volved patients has been reported in a few clinical
studies3,4 and case reports.5,6
A recent systematic review concluded that no
evidence currently existed from controlled studies
and randomized controlled clinical trials to show
whether orthodontic treatment improves or aggravates
the status of periodontally compromised dentitions.7
Hence, in the absence of conclusive evidence,
orthodontists are unable to provide definitive answers
to the queries of such patients. However, in many of
these patients, reconstruction of occlusion and align-
ment of teeth with orthodontic treatment is necessary
not only to prevent periodontal disease progression,
but also to satisfy functional, esthetic, and communi-
cation demands. Therefore, it is important to under-
stand the benefits and risks related to orthodontic
treatment in periodontally compromised patients.
As orthodontic tooth movement is basically a bone
remodeling phenomenon, the effect of orthodontic
treatment on osseous topography in patients whose
bone levels are already compromised is crucial.8
Therefore, in the present study, cone beam computed
tomography (CBCT) was used to assess bony chang-
es. The only CBCT study reporting the effects of
orthodontic treatment on osseous parameters in
periodontally compromised patients cited the lack of
a control group as the limitation to making any solid
conclusions.9
The present study was undertaken to study the
effect of fixed orthodontic treatment on clinical and
radiological periodontal parameters in periodontally
compromised patients. This is the first randomized
controlled study evaluating the effect of orthodontic
treatment on periodontal health in periodontally com-
promised patients compared with a closely matched
control group managed only by periodontal treatment.
MATERIALS AND METHODS
Trial Design, Registration
This was a prospective, randomized, controlled
clinical study conducted in the Department of Ortho-
325
dontics and Dentofacial Orthopedics in collaboration
with the Department of Periodontology Post graduate
institute of Dental Sciences (PGIDS), Rohtak, Harya-
na, India. The Consolidated Standards of Reporting
Trials (CONSORT) guidelines were followed for the
study (Figure 1). Ethical clearance from the Ethics
Committee, Post Graduate Institute of Dental Scienc-
es, Rohtak, Haryana, India, was obtained before
starting the study (PGIDS/IEC/2018/12) and the trial
was registered at clinicalTrials.gov. (NCT03914339).
Subjects
The study sample was selected from patients
reporting to the outpatient department (OPD) of Oral
Diagnosis and Periodontology with the problem of
moderate to severe plaque-induced periodontitis.
Occlusion, function, and esthetics were evaluated in
patients by investigators and Angle Class I non-
extraction malocclusion patients who fulfilled the
inclusion and exclusion criteria (Table 1) were selected
for the study. Patients were given oral and written
information about the study protocol and those who
gave written consent were included in the trial.
Sample Size Calculation
A clinical attachment level (CAL) difference of 1.0 mm
was considered to be of clinical importance between
the test and control groups.7 To detect a clinically
meaningful difference in CAL of 1.0 mm, standard
deviation (SD) of 1.0 mm, with a power of 80%, and an
a-level error of 0.05, 16 patients were needed in each
group. Accounting for a 10% dropout rate, 18 patients
were enrolled in each group (total: 36 patients).
Randomization and Allocation Concealment
All 36 patients received a detailed periodontal
evaluation and parameters were recorded at T0. After
periodontal stabilization, block randomization was
achieved by an investigator (DK) not involved in
providing orthodontic or periodontal treatment or
analyzing results. A block size of 6 was chosen and
possible balanced combinations with three tests and
three controls were generated by using random
allocation software.10 Further random selection of
blocks was done for assignment of all 36 participants.
Clinicians and patients were not blinded due to the
research design. However, the person analyzing the
data was blinded, as all patients and their data were
numbered consecutively.
Test Group (Ortho-Perio, n ¼ 18)
Patients receiving orthodontic treatment after treat-
ment of periodontitis.
Angle Orthodontist, Vol 92, No 3, 2022
326 GEHLOT, SHARMA, TEWARI, KUMAR, GUPTA

Figure 1. CONSORT flow chart for the study. CONSORT indicates Consolidated Standards of Reporting Trials.

Control Group (Perio Only, n ¼ 18) Intervention

Patients managed by achieving and maintaining All 36 study sample patients received a detailed
stable periodontal health for the study duration. These periodontal evaluation and all periodontal parameters
patients were given the option of starting orthodontic used in the study were recorded at baseline (T0)
treatment after 1 year. (Figure 2). After achieving stability of periodontal

Table 1. Inclusion Criteria and Exclusion Criteria for the Studya

Inclusion Criteria Exclusion Criteria

 Good general health  Systemic illness like diabetes, heart disease

 Adult orthodontic patient in the age group 20-40 years  Patients taking medications such as corticosteroids or calcium
with malocclusion due to sequel of chronic generalized periodontitis channel blockers, which are known to interfere with periodontal
 Clinically moderate to severe periodontitis in 2 teeth11 wound healing
 Moderate to severe bone loss as assessed from CBCT12  Pregnant or lactating women
 Smokers
 Noncompliance to oral hygiene measures after Phase I therapy
 Presence of TFO
 Patients with aggressive periodontitis.

a
CBCT indicates cone beam computed tomography; TFO, trauma from occlusion.

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ORTHO-PERIO MANAGEMENT
Figure 2. Patient intraoral pretreatment photographs, panoramic and cone beam computed tomographic images at T1.
results, orthodontic treatment was started in the test
group only, while the control group was kept on
monthly recall for the first 3 months and then every 1
to 3 months as per their periodontal requirements.
Periodontal Management
Professional periodontal treatment was provided to
all patients in both groups as per their requirements,
including professional oral hygiene (POH) and peri-
odontal surgery in the form of open-flap debridement in
sites showing probing depths (PD)  5 mm that bled on
probing even after scaling and root planing at the 4 to 6
week follow-up visit. All patients were prescribed
0.12% chlorhexidine mouth rinse twice daily for 2
weeks after surgery.
Orthodontic Treatment
Orthodontic treatment was started in the test group
using preadjusted edgewise 0.022-in. MBT brackets
(Ortho Organizers, Carlsbad, CA, USA) bonded with
Enlight Light Cure Adhesive (Ormco Corp, Glendora,
CA, USA) using an LED curing light (Galaxy, Light
Cure Unit Cordless, Ahmedabad, India). Special
considerations concerning force systems, anchorage,
and retention were applied during orthodontic treat-
ment11 (Figure 3):
 Use of Copper NiTi wires (Ormco) during leveling
and alignment.
327
 Use of steel ligatures (0.010) and bonded buccal
tubes, with special care taken to remove excess
composite.
 Space closure performed using low and constant
force levels. Anchorage, where needed, was provid-
ed by using miniscrews (FavAnchor, Pune, India).
 Fixed lingual bonded retainers for maxillary and
mandibular anterior teeth will be provided to all
patients after completion of treatment (Multi-strand
stainless steel wire 0.0215-in., G&H Orthodontics,
Franklin, IN, USA).
Data Collection
Clinical parameters. Clinical parameters were
recorded for each patient by same investigator at
three timepoints: T0: Baseline examination (before any
orthodontic and or periodontal treatment); T1: At start
of orthodontic treatment; and T2: 1 year after start of
orthodontic treatment. At T2, major tooth movements
such as alignment and leveling, space closure, and
retraction had been completed in all patients; all
patients were in the finishing stage; and none had
completed treatment.
All clinical parameters were measured in the upper
and lower anterior teeth with a manual periodontal
probe (PCP-UNC 15; Hu-Friedy, Chicago, IL, USA)
and mean values were calculated.
Angle Orthodontist, Vol 92, No 3, 2022
328
Figure 3. Patient intraoral photographs, panoramic and cone beam computed tomographic images at T2.
Radiological parameters. Alveolar bone levels (ABL)
were measured from the cementoenamel junction
(CEJ) to the bone crest on all four surfaces of the
maxillary and mandibular anterior teeth at T1 and T2
for both groups using CBCT (CS 9300). Parameters
used were: field of view (FOV) 10 3 10 cm, voxel size:
180 lm, voltage 90kV, 4 mA current, and exposure
time: 8 seconds.
For standardization, axial navigated coronal and
sagittal reformatted sections were created so the tooth
was visible at the center of its long axis in the mesio-
distal and bucco-lingual planes. This enabled the entire
length of the tooth from the incisal edge to root apex to
be completely visible. A reference line was then drawn
joining the mesial and distal CEJ in the coronal plane
and buccal and lingual extent of the CEJ in the sagittal
plane. The perpendicular distance of the marginal bone
from this reference line was considered as the level of
corresponding alveolar bone.
Subgroup analysis. Subgroup analysis for PD and
CAL sites were analyzed.12 Change in the number of
sites of PD and CAL of these categories at T0, T1, T2
were evaluated and compared between the two
groups.
 Mild periodontitis: PD , 4 mm, CAL: 1-2 mm.
 Moderate periodontitis: PD: 4-5 mm, CAL: 3-4 mm.
 Severe periodontitis: PD  6 mm, CAL:  5 mm.
Angle Orthodontist, Vol 92, No 3, 2022
GEHLOT, SHARMA, TEWARI, KUMAR, GUPTA
Subgrouping of ABL was also done and further
analyzed for a detailed evaluation of bone changes
during orthodontic treatment.13
 Mild periodontitis: radiographic bone loss , 15%.
 Moderate periodontitis: radiographic bone loss: 15%
to 33%
 Severe periodontitis: radiographic bone loss: 33% to
66%
Intra-Examiner Reproducibility
To determine reproducibility of the method, one co-
investigator (ST) recorded clinical periodontal mea-
surements for PD and CAL on 10 patients on two
separate occasions with a 48-hour interval. Similarly,
ABL on CBCT of 10 randomly selected teeth were re-
measured by another co-investigator (AG). Kappa
values of 0.83 for PD, 0.81 for CAL, and 0.81 for
ABL suggested strong intraexaminer reliability.
Statistical Analysis
Data obtained was compiled on an MS Office Excel
Sheet and statistical data analysis was performed
using SPSS v 21.0 (IBM, Armonk, NY, USA). Normality
of numerical data checked using Shapiro-Wilk revealed
that data followed a normal curve. Paired t-tests were
done for intra group and unpaired t-tests for intergroup
comparisons were used to evaluate changes in clinical
ORTHO-PERIO MANAGEMENT 329

Table 2. Comparison of Baseline Parameters Between Test and Control Group Patientsa
Sr. No. Variable Control (n ¼ 18) Test (n ¼ 18) P Value
1. Age 30.11 6 5.17 29.22 6 4.67 .592*
2. Gender 14 (77.7%) female 9 (50%) female .083***
4 (22.2%) male 9 (50%) male
3. Mean clinical parameters – mean 6 SD (95% CI)
PI 1.52 6 0.18 (1.46-1.57) 1.54 6 0.11 (1.54-1.56) .804*
GI 1.40 6 0.20 (1.33-1.46) 1.41 6 0.24 (1.33-1.48) .941*
BOP 0.60 6 0.13 (0.55-0.64) 0.63 6 0.13 (0.58-0.67) .444*
PPD 2.92 6 0.81 (2.65-3.18) 3.29 6 0.75 (3.67-4.16) .164*
CAL 3.12 6 0.78 (2.86-3.37) 3.34 6 0.72 (3.11-3.57) .384*
4. Mean radiological parameters (mean 6 SD) (95% CI)
Mild ABL 1.36 6 0.19 (1.35-1.42) 1.39 6 0.20 (1.32-1.45) .131*
Moderate ABL 3.21 6 0.64 (3.0-3.4) 3.23 6 0.60 (3.0-3.4) .062*
Severe ABL 5.42 6 1.03 (5.18-5.75) 5.46 6 1.02 (5.12-5.79) .602*

*a Unpaired t-test; *** Chi square test.

ABL indicates alveolar bone levels; BOP, bleeding on probing; CAL, clinical attachment level; GI, gingival index; PD, probing depth; PI,
plaque index; PPD, probing pocket depth.

and radiological parameters at different time points (T0,
T1, and T2). CAL, PD, and ABL changes in patients
were evaluated by taking mean 6 SD and comparison
of changes in the frequencies of the three subgroups at
different time intervals were evaluated using chi square
test. For all statistical tests, P , .05 was considered to
be statistically significant, keeping a error at 5% and b
error at 20%, thus giving 80% power to the study.
RESULTS
All 36 patients completed the trial, and healing was
uneventful in all patients.
Table 2 shows that there were no statistically
significant differences at baseline in demographic,
clinical, or radiological parameters between the two
groups.
Table 3 shows the mean values and change in
various clinical periodontal parameters in the test and
control groups before (T0) and after (T2) treatment.
There was a statistically significant improvement (P .
.05) in all clinical periodontal parameters in both the
groups at all-time intervals with no significant differ-
ences between the groups.
Table 4 shows that the radiological periodontal
parameters (ABL) underwent statistically significant

Table 3. Comparison of Change in Clinical Parameters Between Test and Control Group Patients in the Time Period (T0-T2)a
Test Group Control Group
T0 T2 T0 T2 P* Value
PI (total) mean 6 SD 1.53 6 .18 (1.47-1.58) 1.00 6 .14 (0.95-1.04) 1.52 6 0.18 (1.46-1.57) 1.00 6 0.14 (0.95-1.04)
(95% CI) P** ¼ .000 P** ¼ .001
Change T0 –T2 0.53 6 0.19 (0.46-0.59) 0.52 6 0.16 (0.46-0.57) .842
mean 6 SD (95% CI)
GI (total) mean 6 SD 1.41 6 .20 (1.34-1.47) 0.66 6 .14 (0.61-0.70) 1.40 6 .20 (1.33-1.46) 0.93 6 0.14 (0.88-0.97)
(95% CI) P**¼.000 P**¼.000
Change T0 –T2 0.75 6 0.16 (0.68-0.80) 0.49 6 0.17 (0.43-0.54) .750
mean 6 SD (95% CI)
BOP (total) mean 6 SD 0.63 6 .13 (0.58-0.67) 0.02 6 .02 (0.01-0.02) 0.63 6 0.13 (0.58-0.67) 0.04 6 0.02 (0.03-0.04)
(95% CI) P** ¼ .001 P** ¼ .000
Change T0 –T2 0.61 6 0.14 (0.56-0.65) 0.59 6 0.13 (0.54-0.63) .535
mean 6 SD (95% CI)
PD (total) mean 6 SD 3.29 6 0.75 (3.04-3.53) 2.48 6 0.57 (2.29-2.66) 2.92 6 0.81 (2.65-3.18) 2.25 6 0.44 (2.10-2.39)
(95% CI) P**¼.000 P**¼.002
Change T0 –T2 0.81 6 0.43 (0.67-0.95) 0.71 6 0.27 (0.62-0.79) .845
mean 6 SD (95% CI)
CAL total mean 6 SD 3.34 6 0.72 (3.10-3.57) 2.36 6 0.55 (2.18-2.54) 3.12 6 0.78 (2.86-3.37) 2.38 6 0.40 (2.24-2.51)
(95% CI) P**¼.000 P**¼.001
Change T0 –T2 0.98 6 0.1 (0.94-1.01) 0.74 6 0.3 (0.64-0.83) .423
mean 6 SD (95% CI)
* Unpaired t-test; ** Paired t-test.
a
CI indicates confidence interval; SD, standard deviation.

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330 GEHLOT, SHARMA, TEWARI, KUMAR, GUPTA

Table 4. Comparison of Change in Alveolar Bone Level (ABL) Between the Test and Control Groups in the Time Period (T1-T2)a
Test Group Control Group
T1 T2 T1 T2 P* Value
Total mean 3.42 mm þ 1.01 2.94 mm þ 1.0 3.40 mm þ 1.0 3.05 mm þ 1 .03 .56
Difference change 0.48 6 0.29 0.35 6 0.32 .20
Mild total ABL 1.39 6 0.20 (1.32-1.45) 1.26 6 0.22 (1.18-1.33) 1.36 6 0.19 (1.29-1.42) 1.25 6 0.21 (1.18-1.31)
Mean 6 SD (95% CI) P** value .000 P** value .000
Change T1-T2 0.13 6 0.19 (0.06-0.19) 0.10 6 0.17 (0.04-0.15) .844
Mean 6 SD (95% CI)
Moderate total ABL 3.23 6 0.60 (3.03-3.42) 2.97 6 0.59 (2.77-3.16) 3.21 6 0.64 (2.72-3.12) 2.99 6 0.62 (3.00-3.41)
Mean 6 SD (95% CI) P** value .000 P** value .000
Change T1-T2 0.26 6 0.84 (0.01-0.53) 0.21 6 0.41 (0.07-0.34) .460
mean 6 SD (95% CI)
Severe total ABL 5.42 6 1.03 (5.08-5.75) 5.19 6 1.00 (4.86-5.51) 5.46 6 1.02 (5.12-5.79) 5.27 6 1.00 (4.94-5.60)
Mean 6 SD (95% CI) P** Value .000 P** Value .000
Change T1-T2 0.22 6 0.27 (0.13-0.30) 0.19 6 0.25 (0.10-0.27) .152
Mean 6 SD (95% CI)

* Unpaired t -test; ** Paired t-test.

a
CI indicates confidence interval; SD, standard deviation.

improvement from T1 to T2 in both groups. The mean
ABL for test patients at T1 was 3.42 mm 61.01 mm
and at T2 was 2.94 mm 6 1.0 mm. Mean ABL at T1 for
the control group was 3.40 mm 6 1.0 mm and at T2
was 3.05 mm 6 1.03 mm, resulting in a bone gain of
0.48 6 0.29 mm in the test group and 0.35 6 0.32 mm
in the control group.
Subgroup Analysis (Table 5)
The number of sites in the mild, moderate, and
severe categories of CAL, PD, and ABL were
evaluated and a change in the frequencies of the three
subgroups in the test and control groups was seen. In
subgroup analysis for PD, there was a reduction in
99% of severe and 66% of moderate periodontitis sites
and an increase of 42% in mild sites in the test group. A
reduction in 97% of severe and 62% of moderate sites
with an increase of 38% in mild sites in the control
group was found.
CAL subgroup analysis showed a reduction in 71%
of severe and 53% of moderate CAL sites in the test
group with an increase of 55% in mild sites in the test
group, while the control group showed a reduction in
54% of severe and 51% of moderate sites with an
increase of 38% in mild sites. Again, the difference in
the reduction of PD and CAL sites was not statistically
significant between the groups (P  .05). Subgroup
analysis of ABL sites showed a similar trend of
reduction in the number of severe and moderate bone
sites and an increase in the number of mild sites in
both groups. However, the improvement in ABL
periodontitis sites was significantly (P ¼ .004) greater
in the test group than the control group.
DISCUSSION
The fact that orthodontic treatment has been shown
to have small detrimental effects on the periodontium
even in periodontally healthy individuals is a cause of
concern, especially in an already compromised denti-
tion.14 Systematic reviews on this issue have repeat-
edly cited a lack of scientific evidence on the effect of
orthodontic treatment on osseous and non-osseous

Table 5. Intergroup Comparisons of Change in Frequency and Distribution of PD (T0-T2), CAL (T0-T2), and ABL (T1-T2) Sites Between Test
and Control Groups in the Time Intervals Specifieda
Test Group (n ¼ 18) Control Group (n ¼ 18)
Periodontitis Sites Mild Moderate Severe Mild Moderate Severe P *** Value
PD total sites T0 826 (63.7%) 354 (27.3%) 116 (8.95%) 837 (64.5%) 358 (27.6%) 101 (7.79%) .568
PD total sites T2 1175 (90.6%) 120 (9.25%) 1 (0.07%) 1159 (89.4%) 134 (10.3%) 3 (0.23%) .169
Change PD T0-T2 349 (42%) 234 (66%) 115 (99%) 322 (38%) 224 (62%) 98 (97%) .782
CAL total sites T0 667 (51.4%) 445 (34.3%) 184 (14.1%) 680 (52.4%) 452 (34.8%) 164 (12.6%) .514
CAL total sites T2 1035 (79.8%) 209 (16.1%) 52 (4%) 1001 (77.2%) 221 (17.5%) 74 (5.7%) .088
Change CAL T0-T2 368 (55%) 236 (53%) 132 (71%) 321 (38%) 231 (51%) 90 (54%) .090
ABL total sites T1 183 (21.1%) 440 (50.9%) 241 (27.8%) 199 (23%) 428 (42.5%) 237 (27.4%) .647
ABL total sites T2 255 (29.5%) 406 (46.9%) 203 (23.4%) 238 (27.5%) 419 (48.4%) 207 (23.9%) .660
Change ABL T1-T2 72 (39.8%) 34 (8%) 38 (15%) 39 (20%) 9 (2%) 30 (12%) .004
*** Chi square test.
a
ABL indicates alveolar bone levels; CAL, clinical attachment level; PD, probing depth.

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ORTHO-PERIO MANAGEMENT
periodontal parameters in periodontally compromised
patients.1,15 This study attempted to address whether it
is safe to subject periodontitis patients to orthodontic
therapy.16
The present study was designed as a randomized
controlled trial (RCT) and aimed to evaluate the effects
of orthodontic treatment on periodontal tissues in
periodontally compromised dentitions by evaluating
periodontal parameters before, during, and after
orthodontic treatment with a closely matched control
sample to clarify various issues involved in managing
periodontally compromised dentitions. Untreated con-
trols in which orthodontic treatment was not done are
important to account for naturally occurring periodontal
changes and to determine the influence of confounding
factors, thus overcoming a major limitation mentioned
in all earlier studies on this subject.14 The main problem
encountered in the project was to convince the patients
to agree to orthodontic treatment, mainly due to their
apprehension that their teeth would loosen further due
to orthodontic treatment, again stressing the need for
controlled scientific evidence on this subject.
The results of the study showed favorable results of
a combined periodontic-orthodontic treatment in peri-
odontally compromised patients. There was a statisti-
cally significant improvement in all the periodontal
parameters in the control and test groups with a highly
significant CAL gain of 0.74 mm (CI: 0.64-0.83) and
0.98 mm (CI: 0.94-1.01), respectively, from T0-T2. Use
of CBCT enabled evaluation of ABL changes on all four
surfaces of upper and lower anterior teeth and showed
statistically significant improvement in ABL from T1 to
T2 in both groups.
In the absence of RCTs on orthodontic management
of periodontally compromised patients, it was not
possible to compare the findings of the present trial
with other studies. Orthodontic treatment in periodon-
tally compromised dentitions was mainly reported
previously in case reports, case series, and a few
clinical controlled trials, and most reported findings
similar to the current trial, namely improvement in
periodontal health parameters.17,18
However, loss of CAL and ABL has also been
reported.19,20 Thus, positive and negative results have
been reported. Also, most studies4,18 with positive
results focused on the effect of orthodontic treatment
in management of infrabony defects, reporting peri-
odontal parameters in relation to the tooth with such
defects. Absence of randomization and lack of a
control group were some of the other limitations of
those studies, deterring a definite, conclusive result.
This was the first RCT on this subject and, hence, the
results have great clinical significance.
Results of this study were similar to a recent RCT by
Zasciurinskiene et al., which also showed CAL gain
331
and PD reduction.7 However the ABL gain in that study
was very small and insignificant compared to the
current study in which significant bone gain was found.
The authors mentioned lack of control group as their
major limitation, due to which they were not able to
come to a solid conclusion.
An important finding in the current study was that
there was no adverse effect of orthodontic treatment on
either osseous or non-osseous periodontal parameters
in the test group, as evidenced by the non-significant
difference between the two groups, with the values
being toward greater improvement in the test group
(Tables 3 and 4). This was reported in a few other
studies with various reasons hypothesized for this
positive effect of orthodontic treatment.21,22
Vardimon et al. hypothesized that bone repair could
be due to orthodontic treatment acting as a mechanical
stimulus.21 Ogihara et al.22 reported that mechanical
stresses exerted on the alveolar bone led to activation
of angiogenic growth factors like vascular endothelial
growth factor, by which angiogenesis led to osteogen-
esis during bone formation and remodeling. Due to the
clinical nature of the present study, these biochemical
and histological findings could not be confirmed, but
these are important findings to be verified by experi-
mental studies.
The present trial provided an evidence-based
conclusive answer that orthodontic treatment had no
detrimental effect on the periodontal health in peri-
odontally compromised patients if proper periodontal
health was maintained throughout orthodontic treat-
ment. Further studies with larger power, greater
sample sizes, long-term follow-up, and exploring other
aspects involved in routine treatment of adult ortho-
dontic patients, are recommended to verify these
results. Hence, a long-term follow-up of the results is
being continued for this study too.
CONCLUSIONS
 Within the limitations of the study, it can be
concluded that orthodontic treatment does not have
a deleterious effect on periodontal health after
periodontal stabilization in periodontally compro-
mised patients.
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