This article discusses the importance of periodontal health during orthodontic treatment. It notes that poor oral hygiene can lead to decalcification, decay, and gingival infections. The orthodontist should assess the patient's periodontal health and oral hygiene pretreatment. If bleeding or plaque is present, treatment should be delayed until oral hygiene improves. The orthodontist is responsible for ensuring the patient can maintain hygiene during treatment and may need to terminate treatment if hygiene does not improve. Maintaining strong periodontal health leads to on-time case finishes and improved esthetic outcomes and patient satisfaction.

1. Article! Dipak, Freeland1
Periodontics in Orthodontics
January 26, 2013
Introduction:
The field of dentistry has seen significant advances in recent years and
orthodontics is no exception. But the issue of oral hygiene in orthodontics
has remained a perplexing problem.
Patients seek orthodontic treatment mostly for esthetics issue even if
they have functional occlusal problems. The orthodontist and parent or pa-
tient invests time, material, expense and expertise to achieve beautiful
smiles. When the day for appliance removal is finally reached, everyone
from patients, families, and the treating orthodontist and staff are excited.
However, this euphoria is short lived when noticeable decalcification, in the
form of white/brown spots, resulting from poor oral hygiene during treat-
ment ruin the esthetic value of the case. (Figure 1)
Figure 1 Decalcification and
gingival infection post
treatment

2. Article! Dipak, Freeland2
Patients find it difficult to brush and floss around orthodontic appliances.
This leads to a reduction in oral hygiene that results in an increased risk for
developing decalcification, decay and gingival infections. The severity of
the resultant dental caries can range from development of opaque white-
spot lesions (WSL) to the lose of surface integrity of enamel, cavitation and
oral caries and periodontal bone loss. As a profession, we need to focus on
preventive measures and practices to improve oral hygiene and minimize
adverse sequel to the teeth and periodontium.
Orthodontists should be aware of the high risk of WSL and decide at the
patient level whether it is appropriate to start or continue treatment in pa-
tients who are already experiencing enamel demineralization and con-
tinueal gingival inflammation. The risk of developing incipient caries and
gingival lesions during orthodontic treatment should not be underestimated
by orthodontists.
Research indicates that 49.6% of orthodontic patients exhibit enamel
opacities on at least one tooth after orthodontic treatment. There is a sig-
nificant risk that 1 in every 10 bonded teeth is likely to have post-treatment
white spots with the incidence in banded teeth being slightly more at 1 in 9

3. Article! Dipak, Freeland3
teeth. A significant increase in incidence, prevalence and severity of
enamel opacities following orthodontic treatment has also been reported in
the same study. 1
A number of factors are responsible and the authors have attempted to
highlight a few and discuss them.
Factor One: Pretreatment patient assessment
At the initial exam the doctor should perform a complete periodontal
exam that assess the health of the periodontium and the patients oral hy-
giene. If the oral exam shows plaque accumulation and gingival bleeding
then this patient should not be considered for orthodontic treatment until
the gingival tissues are completely healthy. Figure 2
Figure 2: An example of poor
oral hygiene pretreatment.
This type of patient should
not be treated until the gingi-
val problems are rectified.

4. Article! Dipak, Freeland4
Factor Two: How to identify oral hygiene problem patients
With the tooth brush the doctor places the bristles into the sulcus area in
the anterior and posterior areas. If bleeding occurs then there is a hygiene
problem. (Figure 3)
Figure 3: A toothbrush is used in
place of a periodontal probe. This
way the parent/patient can not ac-
cuse the practitioner of cutting the
gums.
Factor Three: How to improve patients oral hygiene.
At this time a preventive dental program should be introduced. If the pa-
tient still shows gingival bleeding after the program then he/she should not
be placed in orthodontic treatment. This program should be designed to

5. Article! Dipak, Freeland5
enhance the diagnosis so the Doctor and patient can discover the oral hy-
giene problems together.
The preventive program has five parts. The first two appointments are 1
week apart and the proper techniques for oral hygiene are taught and re-
viewed. The next three appointments should show complete gingival health
over a 3 months period. If this is not the case then orthodontic treatment
should be withheld from this individual. It is the responsibility of the ortho-
dontist to withhold treatment because if the patient will not take of the teeth
and gums before treatment there oral hygiene will not improve during
treatment. 2
A close relationship with the referring dentist and his hygiene staff will
facilitate the efforts of the orthodontist. Making sure the patient sees the
dentist/hygienist more often may help reinforce the orthodontist efforts to
obtain a disease free mouth.

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Factor four: Oral hygiene problems during appliance therapy (Fig 5)
Figure 5: The appliance system
does increase the oral hygiene
problems.
Once treatment begins the orthodontist is responsible for proper instruc-
tion on how to managed the hygiene issues created by the appliances.
The proper use of the brush and floss should be demonstrated by the doc-
tor. If the doctor spends the time it will impresses on the parent/patient the
importance of oral hygiene. 3
(Figure 6,7)
Figure 6: Flossing should
be demonstrated. Espe-
cially how the patient
gets the floss into the
sulcus.

7. Article! Dipak, Freeland7
Figure 7: Brushing
needs to be taught.
The demonstration
should include how
to get the bristles
into the sulcus.
The doctor should create an appliance environment that enhances the
patients ability to care for the gingiva and enamel. All flash from bonding
and banding should be removed. The use of sealants, such as Proseal, as
part of the bonding procedure should be instituted. The bonding system
should contain fluoride. The use of mechanics systems and retention sys-
tems that make it difficult to clean should be avoided. In the light of the pa-
tients past oral hygiene issues during appliance therapy, bonded retainers,
should be avoided. As bonded retainers are placed “invisibly on the lingual
tooth surfaces, patients’ acceptance is evident. This practice may lead to
the development of carious lesions, favor the formation of plaque and cal-
culus around the mandibular retainers, compared to the maxilla.7

8. Article! Dipak, Freeland8
Zacchrisson, 4 one of the pioneers in the field of bonded lingual retain-
ers, stressed the importance of daily interproximal cleaning with dental
floss. Despite optimal oral hygiene instructions, calculus formed to a
greater extent on the lingual surfaces of the incisors with bonded retainers,
compared with incisors without bonded retainers. 7
The patient is responsible for the care of the teeth and gingival tissues.
if all efforts have failed and the oral hygiene does not improve then the or-
thodontist should consider terminating treatment. Even if it is unilateral de-
cision on the orthodontist part:
Jerrold 6 explains that the doctor-patient relationship is bilateral and
consensually based. He further elaborates that once in existence, this rela-
tionship can be dissolved in 5 ways: (1) both parties agree to end it (a
common example is when the patient is relocating: (2) The patient’s condi-
tion is cured, and no further treatment is required: (3) the doctor or patient
dies: (4) the patient decides to unilaterally terminate the relationship; or (5),
the doctor decides to unilaterally terminate the relationship.
Jerrold further elaborates by suggesting that the doctor can unilaterally
terminate the relationship if the patient breaches at least 1 of the 5 duties
owed to the practitioner under the contract that comprises the doctor-

9. Article! Dipak, Freeland9
patient relationship: (1) the patient is not following the doctor’s instructions
regarding treatment and thus is jeopardizing his own treatment; (2) the pa-
tient is not keeping appointments, thus causing interruptions in the continu-
ity of care, not to mention the interference with the business aspect of the
doctor’s practice: (3) the patient is not being truthful or forthcoming regard-
ing necessary administrative inquires(e.g. his medical history, information
about those financially responsible for his care, his degree of cooperation,
signs and symptoms of problems, and so on); (4) the patient is not con-
forming to accepted modes of behavior (he is belligerent or abusive to the
doctor or his staff,m or is crating a hostile or unhealthy environment in the
office; and (5) the patient is not paying for services rendered. 6 (Figure 8)
Figure 8: A case
where the patient
would not follow oral
hygiene program so
treatment was dis-
continued.
In all fairness to the patient, some patients will exhibit gingival swelling in
response to the appliances during treatment. It begins within a couple of

10. Article! Dipak, Freeland10
months after placement of the appliances. Fixed appliances predispose
plaque accumulation and colonization of bacteria. When gingival tissues
are enlarged, the tooth surfaces/bracket tooth interface become difficult to
access, inhibiting good oral hygiene and resulting in an increase in inflam-
mation and bleeding. The interruption of orthodontic treatment is often ad-
vised when gingival enlargement is diagnosed. The temporary removal of
the irritating factors such as attachments and appliances, debridement,
chlorhexidine prophylaxis, and in some patients, surgical intervention as as
flap/laser surgery, to restore the contour of the enlarged gingival tissues,
can facilitate adequate oral hygiene during subsequent orthodontic treat-
ment. 4
Conclusion:
The benefits to the practice are enhanced in many ways by having all
patients gingiva disease free while under the orthodontic care. Increased
patient referrals will occur because their cases are finished on time with a
beautiful smile that is enhanced by healthy gingival tissues and teeth free
of decalcification. 5 Increased referrals from the dental profession will occur
when their patients are being well taken care of while in the orthodontist

11. Article! Dipak, Freeland11
practice. A study on marketing forces failed to discern or ascertain the
degree/depth of the emotional connection created between the orthodontist
and patient. 5 This doctor patient relationship is the most important aspect
in finishing cases with healthy gingival tissues and free of decalcification.
The patient/parent will differentiate services offered by different prac-
tices. They will choose the practice that develops the bonds necessary to
create the healthy oral environment. This will enhance the patient satisfac-
tion at the end of treatment. Even if the cases are walk-in/google/patients
referral cases, because we will be judged by the general dentists at the oral
hygiene appointments.
Other benefits to the practice are on time finishes. A healthy oral envi-
ronment always finish on time. The esthetic value is always present so at
post treatment consultations the parents/patients are most willing to refer
their friends to your practice. The time spent trying to improve oral health is
one of the best practice building technique. Better then all the marketing
techniques combined. (Figure 9)

12. Article! Dipak, Freeland12
Figure 9: Completed case where the
patient followed the oral hygiene pro-
tocol. Not only did she finish ahead of
time she finished with a great smile.
References:
1. Gorelick
2. Barkley RF. Successful Preventive Dental Practice Amazon
3. Yeung
4. Zachrison
5. Beckwith
6. Jerrold
7. Orsborn
Authors:
Dr Dipak
Dr Ted Freeland DDS, MS Past adjunct professor University of De-
troit orthodontic department. Twice Board certified, Director
Advanced Education in Orthodontics. Private Practice.

13. Research Paper! Last Name 13