periodontal disease as an inflammatory disease triggered by bacteria that supragingivally affect the gingiva (gingivitis) and subgingivally affect

the supporting connective tissue and alveolar bone (periodontitis). The two main characteristics of periodontitis in contrast to gingivitis are connective-tissue attachment loss and alveolar bone loss Incidence: Periodontitis is 2-8% 30 % Etiology: less than 45 years 65-75 years

Bacterial Dental Plaque

Adult (chronic) periodontitis: specific bacterial pathogens Juvenile periodontitis: Actinobacillus actinomycetem comitans (Aa) Risk factors : 1- Psychological stress 2- Lifestyle factors (diet, alcohol and smoking) 3- Deficiencies in immune system 4- Sex ( female > male) 5- Age 6- Diabetes mellitus 7- Osteoporosis 8- PMNL disorders B)Gingival recession: It is the exposure of the root which usually associated with underlying bony dehiscence. causes : Thin biotype (thin soft tissue and bone ). 2- Trauma ( tooth brushing ). 3- Tooth position labially relative to the alveolar bone. 4- Age. 5- periodontal inflammation ( bacterial plaque). 6- Apico-Coronal height of keratinized attached gingiva.

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C)Gingival hyperplasia: May be due to: 1- Bad oral hygiene 2- Mouth breathing. 3- Antiseizure medications eg phenytoin 4- Ca channel blockers eg nifedpine 5-delayed apical migration of the gingival margins of the teeth D) Clinical assessment of periodontal condition.

A) Clinically: 1- Evaluating the appearance of the tissue ( color, texture, degree of plasticity ) 2- Severity of inflammation ( bleeding on probing immediate or delayed-copious or minimal or suppurative ) 3- Changes in the level of soft tissue attachment ( GR, pocket depth and attachment level ) B) Radiographically: To assess the periodontal condition indirectly.

Interrelationship of Orthodontic Tooth Movement with Periodontal Health A) Loss of periodontal attachment and bone relative to orthodontic therapy . Orthodontic ttt cause no significant long-term effects on periodontal attachment and bone level. But in patient with active periodontitis orthodontic ttt might accelerate the disease process. ( PDL defect not PDL lesion ). Types of tooth movement as it related to loss or gain of periodontal attachment:

A) Bodily movement: can be done by moving the teeth into periodontal defect and gaining proper soft tissue attachment after lesion elimination . B) Intrusive movement: not gain a new attachment alone but must be in conjunction with barrier attachment procedure. (GTR) C) Extrusive movement: can shallowing the infra-bony defects by coronal positioning of intact connective tissue attachment If there is furcation involvement in the tooth to be uprighted, however, orthodontic tooth movement may exacerbate the periodontal problem

Tooth movement into areas of remodeled edentulous spaces (that is, constricted bone areas) with slow, light orthodontic forces is often possible, depending on the width ratio of tooth to bone, but alveolar bone loss and posttreatment space opening can be common sequelae, even under optimal conditions.

B) Gingival recession relative to orthodontic therapy. It related to: 1- proper oral hygiene. 2- proper placement of the orthodontic appliances without excessive adhesive flashes.

Patient Management Protocol For Dental Team Members A)Suggested protocol Before orthodontic therapy: 1- Patient is practicing excellent oral hygiene . 2- The periodontist must provide the orthodontist with: a- Copy of patient recent PDL charting. b- Recent anterior radiographs and bitewing radiograph. c- Written clearance statement that the patient may safely begin orthodontic ttt. If the periodontist not provide the charting and PDL statement the orthodontist is obliged to refer the patient to periodontist or make it him-self. Patients with excellent oral hygiene and no evidence of periodontal disease: it is safe to begin orthodontic ttt Patients with evidence of periodontal disease: Orthodontic ttt must be postponed and referred to periodontist to receive proper ttt followed by 2-4 months healing and observation period then re-evaluated to receive the orthodontic ttt B)Suggested protocol During orthodontic therapy. Reevaluation at 6 weeks to 6 month depending on the condition and risk factors of each patient especially to patients with history of periodontal disease. C)Suggested protocol After orthodontic therapy: After observation of many patients after removal of the orthodontic appliance they maintain the good oral hygiene habit they used to during the orthodontic ttt. Proper orthodontic ttt in patients with excellent oral hygiene and the absence of significant periodontal disorder should not pose any significant periodontal risk. In the presence of poor oral hygiene, however, and under circumstances of certain type of periodontal disorder , fixed orthodontic appliance and tooth movement can contribute to significant deleterious periodontal consequences.

The interdisciplinary team of periodontist and orthodontist can manage the majority of interrelated orthodontic periodontal problems with minimal risk and predictably successful outcomes.

Electric TOOth brush powered toothbrushes are more effective in preventing gingivitis than manual toothbrushes Statistically significant comparative effectiveness in reducing both gingival index and gingival bleeding scores was observed only for the side-to-side-acting toothbrush the use of powered toothbrushes results in a slight, but significant, reduction of gingival bleeding or inflammation, compared with manual toothbrushes.

single-tooth anterior crossbites often result in stripping of the attached gingiva of lower incisors, and severe impinging deep bites may lead to destruction of the palatal soft tissues. Plaque control important in the management of periodontal conditions, orthodontic therapy can be considered equally important to facilitating this process.

Pocket depth Gingivitis Bone loss Pocket depth Ging recession Attachment loss

0.3 mm deeper Similar no. of bleeding sites 0.13 mm greater 0.23 mm deeper 0.03 mm greater 0.11 mm greater 0.05 less 0.06 less

Gingivitis

BOP 6 points lower 23.8 points lower

Absence of reliable evidence describing positive effects of orthodontic treatment on periodontal health. The existing evidence suggests that orthodontic therapy results in small detrimental effects to the periodontium

There are some malocclusions that harm the periodontium, such as an anterior deep bite, which strips the gingiva on the maxillary incisors, or an anterior crossbite that results in recession and mobility of a lower incisor The finding that a malocclusion is associated with periodontal disease does not prove causation. Therefore, its elimination (through orthodontic treatment) may have no effect on periodontal health. Periodontal health is influenced by numerous factors. Malocclusion and orthodontic treatment may have only a limited effect compared to behavioral influences (smoking, oral hygiene, diet) and genetic conditions The systematic review on the effects of a malocclusion on periodontal health suggests that subjects with a malocclusion have worse periodontal health than subjects without a malocclusion. The systematic review on the effects of orthodontic treatment on periodontal health identified low-quality evidence suggesting that orthodontic therapy results in small detrimental effects to the periodontium

The exact aetiology of chronic hyperplastic gingivitis is unknown, although plaque is accepted to be the principle causative factor.1 It is also recognised that certain individuals are rendered susceptible by genetic and/or environmental factors. These include polymorphisms in the gene for interleukin 1, cigarette smoking, leukopenia, and diabetes among others. In these situations, CHG leads to periodontitis and loss of attachment over time. in the short term (up to 5 months), significant reductions in plaque levels can be expected when an OHP programme is instituted for patients undergoing fixed appliance treatment. This is because smoking not only favours the development of gingivitis and periodontitis (among other conditions), but because periodontal cell turnover is slower in smokers,38 tooth movement is slower resulting in longer treatment times and orthodonticinduced gingivitis acting over a longer period of time. Thus any loss of attachment is likely to be of a greater significance in smokers undergoing fixed appliance orthodontic treatment. treatment strategies to minimise plaque build up around fixed appliance components For example, the use of small brackets with relatively small occlusogingival

dimensions39 and bracket positioning gauges may help to provide consistent bracket placement avoiding unnecessary proximity to the gingival margins and thus assist in reducing plaque accumulation. Brackets with minimised labiolingual/buccolingual profile and ensuring all excess bonding adhesive is removed may also reduce plaque accumulation. Similarly, for patients where calculus build up occurs during orthodontic treatment around the fixed appliance components, regular scaling and polishing and the use of an appropriate anti-plaque and anti-calculus mouthwash are advisable. Complex bracket designs such as self-ligating varieties containing relatively large clips, auxiliary arch wires and other auxiliaries are plaque retentive and should probably be avoided in periodontally susceptible orthodontic patients An OHP programme for patients undergoing fixed appliance orthodontic treatment produces a shortterm reduction (up to 5 months) in plaque and improvement in gingival health. No particular OHP method produces a greater short term benefit to periodontal health during fixed appliance orthodontic treatment.

Gingival invagination is an alteration of the ginviva often observed during orthodontic space closure. This finding appears as a pseudopocket which can be probed both horizontally and vertically. After tooth extraction, orthodontic space closure is usually performed, and changes of the gingiva are frequently observed. As a result, a gingival infolding, a so-called gingival invagination, develops . the gingival pseudopocket is defined as a linear invagination in the interproximal tissue in mesial and distal directions, with a probing depth of at least 1 mm Although this is a very frequent finding affecting between 35% and 100% of patients One theory is founded on mechanical considerations During orthodontic space closure, pressure and tension zones develop. Tissue is stretched in the areas under tension. The epithelium is loosened from the tooth being moved and a red patch arises [4]. In the pressure zone, gingival tissue and the underlying alveolar bone are compressed favoring the infolding of the gingiva [4, 13]. The epithelium and connective tissue in the affected region show signs of proliferation, with the ingrowth of blood vessels and loss of collagen bone topography in the extraction area. if tooth closure is delayed, there is enhanced atrophy and reduction in bone density in the alveolar process in the extraction area.

Intermediate to long-term consequences of gingival invagination gingival invagination can hinder orthodontic space closure. Due to tissue hyperplasia, space closure is often inadequate and may take more time. They also demonstrated that gingival invagination has negative effects on marginal bone by seriously reducing the height of interdental bone [34]. The stability of bone closure may be at risk As gingival invagination is located interdentally and may be relatively deep, it can provide an ideal site for plaque and bacteria accumulation. indicate that the epithelial hyperplasia in gingival invagination may mask the inflammatory reaction of subclinical gingivitis.

gingival invagination decreases with time, it may persist over long periods and impair the patient's oral hygiene ability.

Approaches for preventing gingival invagination early orthodontic space closure is reasonable, as it decreases the probability of gingival invagination used a socket preservation technique with a nonresorbable GoreTex membrane after tooth extraction Approaches for treating gingival invagination it is recommended that excess tissue in gingival invagination be removed conventional gingival excision was compared with piezosurgery. surgical excision of the tissue, followed by filling the osseous defect with bovine bone graft and complete orthodontic space closure. With regard to the factor time, the clinician may consider approaches such as a segmented procedure or alignment before extraction when planning orthodontic treatment If atrophy of the alveolar ridge has already occurred (a connective tissue graft or bone splitting might be effective.