adverse effect of orthdontic ttt

 Adverse effects of orthodontic treatment: A clinical perspective

1. Introduction 

Orthodontic treatment is a discipline in dentistry, like many 

other disciplines in this field, it can have adverse effects associated with the execution of treatment. These effects can be 

related to the patient or practitioner. Some of these effects 

are not fully understood, such as root resorption, and others 

are associated with orthodontic treatment without supporting 

evidence. Consideration of risk factors prior to treatment is 

important. Only risk factors that have been supported by 

previous evidence will be reviewed in this article. These adverse 

effects include root resorption, pain, pulpal changes, periodontal disease, decalcification, and temporomandibular dysfunction (TMD). 

2. Root resorption 

Root resorption is common during orthodontic tooth movement . Limited root resorption, involving a 

number of teeth, can be considered a consequence of orthodontic treatment . If the patient develops 

additional pathosis, such as periodontal disease, this may further compromise the support of the tooth and the patient can 

eventually loose that tooth . However, no 

reports in the literature have documented tooth loss caused 

by root resorption. A long-term case report documented a 

follow-up of a case of severe root resorption that occurred 

for 33 years, and the affected teeth were found to be functional 

 However, lack of reports in the literature on 

tooth loss due to root resorption does not exclude this as a 

potential risk. 

The problem of root resorption as a consequence of orthodontic treatment was first discussed by . He 

was also the first to indicate other factors, such as hormonal 

disturbance and dietary deficiency in addition to orthodontic 

treatment variables, which may be contributing factors in root 

resorption . The etiology of root 

resorption still remains unclear and is complex, including genetic predisposition and environmental factors (Al-Qawasmi 

The best approach toward root resorption is to consider the 

risk factors, discuss the identified factors with the patient seeking orthodontic treatment, and include these factors in the 

treatment consent form. These risk factors include the duration of treatment. The risk for root resorption increases with 

the length of treatment 

documentation of the condition through pre-treatment periapical 

radiographs of the maxillary and mandibular incisors is necessary. Potential extraction of maxillary and mandibular first or 

second premolars as well as the use of intermaxillary elastics 

during treatment should also be considered 

Orthodontic re-treatment of such cases should be performed 

with caution and treatment objectives should be limited. Some

habits, such as thumb sucking, occlusal trauma, or history of 

chronic bruxism, may increase the risk for root resorption 

Assessment of the condition through a progress radiograph 

at 6–12 months after the initiation of orthodontic treatment is 

recommended. These could be either periapical or panoramic 

radiographs. The patient must be informed that if root resorption is observed, then active treatment must be stopped for at 

least 3 months  The reparative process 

of root resorption begins two weeks after active treatment is 

stopped . At this stage, an alternative treatment plan should be considered and treatment should be discontinued when severe root resorption is observed. 

3. Pain associated with orthodontic treatment 

Pain and discomfort is a common adverse effect associated 

with orthodontic treatment . Previous studies 

have shown that 70–95% of orthodontic patients experience 

pain. This pain could be a reason for discontinuing treatment; 

previous studies have indicated that 8% and even upto 30% of 

orthodontic patients discontinue treatment because of pain 

). The pain and discomfort associated with orthodontic treatment is characterized by pressure, tension, or soreness of the teeth . Pain in the anterior teeth 

is greater than the posterior teeth.

 Pain 

has been reported to begin 4 h after the placement of separators or orthodontic wire, and the worst pain was found to occur on the second day of treatment 

pain lasts for seven days). Clinical anticipation of the need to use fixed appliances makes the risk for pain 

and discomfort greater  

Management of pain should include informing the patient of 

the possibility of experiencing pain to reduce anxiety. Furthermore, the clinician can ask the patient to chew on plastic wafers or chewing gums containing aspirin

Hwang et al.

. Chewing on plastic wafers theoretically increases the circulation in the periodontal 

ligament, which reduces the pain and discomfort. Additionally, clinicians are recommended to prescribe Ibuprofen or 

acetaminophen analgesics preoperatively and for a short 

duration after the placement of separators and initial wires 

4. Pulpal changes during orthodontic treatment 

Pulpal reaction to orthodontic forces is minimal. This reaction 

is in the form of transient mild inflammatory response, which 

has no long term significance. 

The possibility of pulp vitality loss 

during orthodontic treatment does exist. 

The risk factors for loss of pulp vitality include 

a history of trauma associated with the teeth. Pre-treatment 

periapical radiographs of previously traumatized teeth are 

essential for comparative purposes. Additionally, the use of 

heavy uncontrolled, continuous forces by the orthodontist or 

round tripping of the teeth may lead to loss of pulp vitality. 

Therefore, orthodontist should use optimal light forces during 

their treatment

5. Periodontal disease and orthodontic treatment 

Periodontal disease includes gingivitis, alveolar bone loss (periodontitis), and loss of attached gingival support. 

The periodontal reaction toward orthodontic 

appliances depends on multiple factors, such as host resistance, 

the presence of systemic conditions, and the amount and composition of dental plaque. Lifestyle factors, including smoking,.......................

can also compromise periodontal support ; 

. Additionally, the negative effects of uncontrolled diabetes on periodontal support 

are well established

Orthodontic treatment in uncontrolled diabetic individuals is 

contraindicated. 

Bacteria present in dental plaque are the primary causative 

agent of periodontal disease (Sanders, 1999). Orthodontic 

treatment with fixed appliances is known to induce an increase 

in the volume of dental plaque. However, fixed orthodontic 

appliances cause a shift in the type of bacteria. Therefore, fixed orthodontic treatment may result in 

localized gingivitis, which rarely progresses to periodontitis 

The factor that determines the condition of the periodontium during orthodontic treatment is the level of oral hygiene. 

Therefore, oral hygiene instructions should be given before the 

initiation of orthodontic treatment and reinforced during every 

visit. Regularly brushing the teeth is the first line of defense in 

controlling dental plaque. The use of electrical and ultrasonic 

tooth brushes has been shown to be superior to manual brushing in controlling bacterial plaque on the buccal surfaces and 

reducing gingival inflammation. The use 

of an interproximal brush in addition to the orthodontic brush 

is necessary. The fluoride concentration in 

the toothpaste used for brushing should not be less than 

0.1%. The use of toothpaste with stannous fluoride produced 

a higher inhibitory effect on dental plaque and gingivitis development. 

The use of fluoride and chlorohexidine varnishes reduces the levels of bacterial plaque . Oral hygiene during orthodontic treatment is the 

key to maintenance of a healthy periodontium. 

Orthodontic treatment of patients with active periodontal 

disease is contraindicated as the risk for further periodontal 

breakdown is markedly increased.

 Complete evaluation 

of the periodontal status, especially in adult patients, is required and control of the periodontal status is necessary prior 

to initiation of orthodontic treatment. 

Careful examination of the level of attached gingival prior 

to comprehensive orthodontic treatment is necessary. The level 

of attached gingival is measured from the free gingival margin 

to the mucogingival junction minus the depth of the gingival 

sulcus. Dental movement in the labio-lingual direction can 

be performed within the envelope of the periodontium without 

harmful effects on the level of attached gingiva .

 If an inadequate level of attached gingiva is present 

prior to orthodontic treatment, a periodontic consultation 

should be performed, especially if labial movement of the teeth 

is anticipated . 

6. Decalcification and caries associated with orthodontic 

treatment 

Decalcification of enamel (white spots) is a common adverse 

effect of orthodontic treatment. Decalcification is considered 

to be the first step toward cavitation. Decalcification of enamel 

occurs in 50% of orthodontic patients and the most affected 

teeth are the maxillary incisors. 

Additionally, these lesions can develop within four weeks, which 

is the typical time span for orthodontic follow-up. 

The prevention protocol for decalcification includes plaque 

control through brushing of the teeth with fluoridated tooth 

paste. Daily rinsing with a 0.02% or 0.05% sodium fluoride 

solution can also minimize decalcification of enamel.

 Additionally, fluoridated solutions may delay the progression of lesions cannot be controlled. 

8. Conclusion 

Orthodontic treatment is like any other treatment that can be 

associated with unfavorable side effects. Knowledge of these 

side effects is essential to the orthodontist and the patient willing to have orthodontic treatment. Obtaining an informed 

consent from the patient is as important as executing the treatment plan. 

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