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HERRERA ET AL .
Background
From evidence to recommendation — additional considerations
Intervention
Acceptability Patients usually accept and understand the need for long-term supportive care.
The use of orthodontic appliances is associated with increased micro- bial colonization and increased plaque retention; hence, OT is often associated with gingival inflammation and a transient shift of the sub- gingival microbiota. It is, therefore, important to implement an appro- priate oral hygiene and periodontal management protocol throughout OT to ensure periodontal health and avoid adverse effects like enamel demineralization, tooth discolorations, and further loss of periodontal support. Although, in some patients, an acceptable oral hygiene level can be attained, professional plaque control and other supportive oral and periodontal care must be implemented following the patient's risk profile.
Feasibility, ethical, economic and legal considerations There are no specific considerations.
R7.8. How should we attain stability of the orthodontically treated dentition in stage IV periodontitis patients?
Additional question addressed by the WG
R7.8: Expert consensus-based recommendation We recommend that an appropriately designed permanent fixed passive retention (with or without additional removable retention) is used after the completion of orthodontic therapy . We also recommend that patients enter a life-long supporting protocol to identify early retainer failures and/or undesired tooth movements . Supporting literature (Han et al., 2020) and Expert opinion Quality of evidence Low (expert opinion) Grade of recommendation GradeA — "" Strength of consensus Consensus (0% of the group abstained due to potential CoI)
Available evidence
Number and design of included studies The evidence for this recommendation is derived from expert opinion and from a randomized trial with 48 patients, comparing three differ- ent periodic periodontal scaling protocols (every month, every 3 months or every 6 months) for the maintenance of periodontal health in adolescents with fixed orthodontic appliances (Jiang et al., 2021). A systematic review (Arn et al., 2020) assessed the avail- able evidence in the literature for the effects of fixed orthodontic retainers on periodontal health. It included 11 RCTs, 4 prospective cohort studies, 1 retrospective cohort study and 13 cross-sectional studies.
Background
Risk of bias Not applicable.
Intervention
Effect sizes and their clinical relevance One RCT reported that periodontal scaling conducted monthly or once every 3 months during OT was more effective (in terms of PI, GI, PPD and crevicular inflammation biomarkers) than scaling adminis- tered once every 6 months. The systematic review concluded that the use of fixed orthodontic retainers was compatible with periodontal health, or at least not associated with detrimental effects on the periodontium. Even though the RCT and the systematic review studied peri- odontally healthy patients and not adults with stage IV periodonti- tis, it is expected that these findings can be reasonably extrapolated.
Post-orthodontic relapse of the moved teeth towards their pre- treatment positions is often observed and can have aesthetic and functional consequences that compromise treatment outcomes and patient satisfaction. Therefore, some type of retention, either with removable or fixed appliances, is usually implemented depending on the pre-existing malocclusion, the type of tooth movements carried out, and patient preferences. Fixed retention is usually considered superior to removable appliance in terms of reducing post-treatment relapse, especially in anterior crowding (Littlewood et al., 2016). How- ever, at the same time, it may be more prone to retention failure in the short or the long term, might lead to more plaque accumulation or gingival inflammation, and might even lead to inadvertent tooth movements due to the distortion of the bonded wire. It is, therefore, advisable that fixed retention (with additional removable appliances, if needed) is used after OT in patients with stage IV periodontitis, but a long-term supportive care protocol should be implemented to assess not only periodontal health, but the integrity of the retention appli- ances and the stability of the treatment outcomes.
Consistency, balance of benefit and harm Not applicable.
Overall certainty of the evidence Low, expert opinion.
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