Lingual orthodontics is an exciting tool for the treatment of orthodontic conditions, especially attractive for adult patients reluctant to conventional buccal methods. This treatment modality, although similar in its goals to conventional orthodontics, poses particular difficulties that may affect treatment outcome. These should be properly addressed from the beginning of treatment, namely at data collection and diagnosis, and then throughout the treatment to its final stage.
Orthodontics and periodontal disease
The two prevalent oral diseases - dental caries and periodontal diseases, should be treated prior to orthodontic therapy. Caries control is usually incorporated into routine dental checkups. However, periodontal disease, which exists in many forms, is often not accurately diagnosed and treated. This is especially significant in adult patients, where prevalence of periodontal disease is high, with gingival bleeding in 43.6% and attachment loss of more than 4 mm in 24.1% of the American population (1). Epidemiologic studies reveal that severe and advanced periodontal disease occurs in up to 8% of people younger than 45 and 30% of people aged 65 to 75 (2,3,4). In view of these data it is evident that planning orthodontic treatment in the adult patient should routinely include a thorough periodontal evaluation and treatment.
In the presence of excellent oral hygiene and absence of periodontal disease, proper orthodontic treatment should cause no significant effect on periodontal parameters, namely, attachment levels and bone levels (5). However, in patients with active periodontal disease, even with relatively good oral hygiene, orthodontic tooth movement may accelerate the disease process (6,7). If periodontal disease and sub-gingival plaque are not controlled before and during orthodontic treatment, loss of attachment will likely follow.
Gingival hyperplasia, a side effect of orthodontic treatment is frequently related to poor oral hygiene combined with improperly positioned appliances in close proximity to gingival tissues. Severe cases of gingival hyperplasia may lead to attachment loss(5) due to a change in microbial ecosystems in the sulcular/pocket area leading to periodontal disease initiation and progression.
Risk management points at the importance of detecting and treating periodontal disease before and during orthodontic treatment (8). This is especially true of the adult patient who may be more at risk of having active sites of periodontal disease. In this environment orthodontic movement may accelerate periodontal breakdown, leading to treatment failure which may contribute to liability issues.
Lingual orthodontics and periodontal tissues
The main feature of lingual orthodontics, namely, its invisibility, makes it a culprit to periodontal heath. Appliances are positioned in hidden areas of teeth, more prone to improper oral hygiene, therefore increasing the risk of developing periodontal breakdown or accelerating existing disease if not properly treated. Appliance position results in further technical difficulties, including their relative bulkiness, gingival proximity and the difficulty to remove excessive adhesive flashes. It is therefore imperative to develop a proper patient management protocol, both for the benefit of the patient and the dental team and from a risk management point of view.
Patient management protocol
It is advisable that this protocol be implemented for every patient. However it is particularly important for adult patients, where interdisciplinary treatment requires a concerted effort of the entire dental team including the orthodontist, periodontist, prosthodontist and/or general dentist (9) and especially so if lingual orthodontic treatment is planned.
Before orthodontic treatment:
- Every member of the dental team should participate in developing the treatment plan and be aware of his role in its execution. Additionally, every member of the dental team must make sure that the patient is practicing excellent oral hygiene.
- Complete periodontal evaluation including a parallel technique periapical x-ray survey, periodontal charting including pocket probing and examination. This should be performed by the dentist or the periodontist. Lack of proper diagnosis and treatment might expose the orthodontist to unnecessary liability issues later on.
- Treatment planning must include the different elements of treatment and their temporal sequence. Initial therapy would include treating and curing diseases, such as caries, gingivitis and periodontitis. This may include periodontal surgery aimed at eliminating plaque retentive areas such as deep pockets, particularly where orthodontic treatment is anticipated. Orthodontic treatment should be staged only after initial therapy, usually before definitive prosthetic treatment and sometimes as a preparatory phase to it. Other elements, including dental implants can be executed before or after orthodontics, as appropriate. Most patients look forward to the esthetic improvement resulting from orthodontic treatment without realizing that it can be dangerously jeopardized by improper periodontal health. . It is advisable to discuss with the patient the different treatment phases, the locations of their execution, namely the general dentist, the orthodontist and the periodontist, and their time sequence.
- For patients with excellent oral hygiene and no evidence of periodontal disease, a written statement that the patient may begin orthodontic treatment is advisable.
- Patients with periodontal disease should be treated prior to orthodontic treatment. Orthodontic treatment should be postponed until periodontal stability is achieved. Treatment may include instructions in proper oral hygiene, scaling and root planing and, where appropriate, periodontal surgery. It is strongly recommended that periodontal treatment be done in a periodontal environment, by a periodontal team. Following a healing period of 6-16 weeks, if patient home care commitment is evident, oral hygiene is excellent and no signs of active disease are present, namely, pocketing, bleeding on probing, suppuration etc. the periodontist can provide the orthodontist with a written clearance to commence orthodontic treatment.
During orthodontic treatment:
- Continuous reevaluation should be performed during orthodontic treatment, the frequency of which would depend on particular circumstances, every 1-6 months. Limited practices such as those limited to periodontics or to orthodontics should collaborate in treating adult patients, including lingual orthodontics patients, in this phase of treatment. Therefore, this periodic reevaluation, although possibly done within the orthodontic environment, should preferably be done by the periodontist.
- In most cases periodontal maintenance, including plaque control and plaque and calculus removal should be performed every 6 weeks. However, the frequency of maintenance should be adjusted according to circumstances and may vary from 4 weeks in advanced cases to 12 weeks in very compliant, disease free cases. From a practical point of view this treatment phase is most difficult because it temporally combines two treatment modalities performed in two different offices. The patient must be seen both by the orthodontist and the periodontist. Cooperation and communication greatly enhance the outcome of this phase and would be best discussed with the patient and within the dental team before commencement of treatment.
- Orthodontic treatment should be terminated if patients develop signs of periodontal breakdown.
After orthodontic treatment:
- A thorough dental and periodontal reevaluation.
- Oral hygiene instructions. At this time-point many patients would benefit from detailed re-education in order to avoid aggressive brushing and learn about maintenance of the teeth in their new position and without the lingual appliances. |
References
1. Albandar JM. Periodontal diseases in North America. Periodontology 2000 2002 Vo. 29, 31-69.
2. Papapanou PN, Wennstr?m JL, Gr?ndahl K. Periodontal status in relation to age and tooth type: a cross-sectional radiographic study. J Clin Periodontol 1988;15:463-478.
3. Papapanou PN, Wennstr?m JL, Gr?ndahl K. A 10-year retrospective study of periodontal disease progression. J Clin Periodontol 1989;16:403-411.
4. Hugoson A, Jordan T. Frequency distribution of individuals aged 20-70 years according to severity of periodontal disease. Community Dent Oral Epidemiol 1982;10(4):187-192.
5. Boyd RL, Leggot PJ, Quinn RS, Eakle WS, Chambers D. Periodontal implications of orthodontic treatment in adults with reduced or normal periodontal tissues vs. those of adolescents. Am J Orthod Dentofacial Orthop 1989;96(3):191-198.
6. Thilander B. Infrabony pockets and reduced alveolar bone height in relation to orthodontic therapy. Semin Orthod 1996;2(1):55-61.
7. Wennstrom JL, Lindskog-Stokand B, Nyman S, et al. Periodontal tissue response to orthodontic movement of teeth with infrabony pockets. Am J Orthod Dentofacial Orthop 1993;103:313-319.
8. Machen DE. Legal aspects of orthodontic practice: risk management concepts. Am J Orthod Dentofacial Orthop 1990;98(1):84-85.
9. Sanders NL. Evidence based care in orthodontics and periodontics: a review of the literature. J Am Dent Assoc.
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