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HERRERA ET AL .
teeth with healthy (non-inflamed)
reduced periodontal
R7.2. In stage IV periodontitis patients, when should orthodontic therapy (OT) start?
support.
Consistency All the referred pre-clinical investigations report consistent results indicating that when periodontitis is not adequately controlled, OT will result in further tissue destruction, evidenced by loss of periodon- tal attachment and alveolar bone. Balance of benefit and harm These unwanted effects (further loss of periodontal attachment and bone) clearly outweigh the benefit of OT and hence orthodontic tooth movements should not be started until periodontal inflammation is arrested, when fulfilling the well-established end points of periodontal therapy (Sanz, Herrera, et al., 2020).
Additional question addressed by the WG
R7.2: Expert consensus-based recommendation In successfully treated stage IV periodontitis patients in need of orthodontic therapy , we recommend starting OT once the endpoints of periodontal therapy have been achieved [no sites with PPD = 5mm and BOP and no sites with PPD ≥ 6mm ( Sanz, Herrera, et al., 2020 )] . Supporting literature Expert opinion; data from pre-clinical studies Quality of evidence Low (expert opinion) Grade of recommendation GradeA — "" Strength of consensus Strong consensus (0% of the group abstained due to potential CoI)
Overall certainty of the evidence Low, expert opinion.
Background
From evidence to recommendation — additional considerations
Intervention
OT is indicated for the functional and aesthetic rehabilitation of stage IV periodontitis patients with pathological tooth migration, characterized by tooth elongation, drifting and flaring. This OT must fulfil its objectives without jeopardizing the short- and long- term outcomes of periodontal therapy and hence it is important to stage it appropriately within the overall patient's treatment plan.
Acceptability Patients usually accept and understand, once they have been explained the balance of the associated benefits versus harms, that OT can only be implemented once periodontal therapy has been completed and the end points of periodontal therapy have been reached. Feasibility, ethical and economic considerations The only perceived barrier is the length of overall treatment, but since the benefits clearly outweigh this inconvenience, this barrier is usually well accepted. There are no ethical or economic considerations.
Available evidence
Number and design of included studies The evidence for this recommendation is derived from expert opinion and from experimental in vivo investigations.
Legal considerations There are no legal considerations.
Risk of bias Not applicable.
R7.3. How should we manage stage IV periodontitis patients with pathological tooth migration (flaring, drifting and elongation)?
Effect sizes and their clinical relevance The evidence derives from well-controlled pre-clinical in vivo investigations (Eliasson et al., 1982; Ericsson et al., 1977; Melsen, 1986; Wennstrom et al., 1993) and clearly indicates that when periodontitis is not fully treated (inflammation is not arrested) prior/during OT, these orthodontic (biomechani- cal) forces within the periodontal tissues with remaining inflammatory processes will re-initiate and/or accelerate the progression of periodontal destruction, leading to further loss of clinical attachment and supporting alveolar bone. In con- trast, no detrimental effects of orthodontic tooth movements have been observed when these movements are exerted on
PICOS question addressed by a SR
R7.3: Evidence-based recommendation In stage IV periodontitis patients with pathological tooth migration , we suggest undertaking orthodontic therapy once the endpoints of periodontal therapy have been reached , based on the evidence that this therapy : a. does not significantly affect periodontal outcomes [CAL , PPD , and radiographic bone levels (RBL)] ;
b. seems to reduce gingival inflammation (BOP) ; c. does not significantly alter gingival margin levels ;
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