2009;140(5):575-576 JADA

Mina H. Chung and Robbie W. Henwood

Orthodontic Therapy on Periodontal Health
Inconclusive Evidence of the Effects of
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JADA, Vol. 140 http://jada.ada.org May 2009 575
RESEARCH CRITICAL SUMMARIES
Inconclusive evidence of the effects of
orthodontic therapy on periodontal health
A critical summary of Bollen AM, Cunha-Cruz J, Bakko DW, Huang GJ, Hujoel PP. The effects
of orthodontic therapy on periodontal health: a systematic review of controlled evidence.
JADA 2008;139(4):413-422.
Mina H. Chung, DDS, MS; Robbie W. Henwood, DDS, PhD
Systematic review conclusion. The association between orthodontic therapy
and improved periodontal health cannot be verified. However, limited evidence
suggests a slight worsening of periodontal health after orthodontic therapy.
Critical summary assessment. On the basis of evidence from only 12 studies
with substantial risk of bias, there is an absence of reliable evidence supporting
the positive effects of orthodontic therapy on patients periodontal status.
Evidence quality rating. Limited.
Clinical question. Does contempo-
rary orthodontic therapy affect peri-
odontal health?
Review methods. The authors
conducted a comprehensive search
of the literature from January
1980 to June 2006, searching eight
databases electronically and six
dental journals by hand. This
search identified 3,552 titles and
abstracts, 12 of which were full
articles that met the inclusion cri-
teria. The authors included one
randomized controlled trial (RCT),
three cohort studies and eight
cross-sectional studies in which
researchers compared untreated
patients with patients who under-
went contemporary orthodontic
treatment and in which the inves-
tigators conducted posttreatment
evaluations of periodontal health.
The authors included studies
involving both fixed and removable
treatment modalities, but they
excluded studies involving full-
banded and orthognathic surgery
and distraction osteogenesis. The
article describes the reasons for
this exclusion.
Main results. There was incon-
clusive evidence to support any posi-
tive association between orthodontic
therapy and periodontal health.
This finding was due to the absence
of direct evidence of the positive
effects of orthodontic therapy on
periodontal health. Some evidence
suggests a small mean worsening of
periodontal health after orthodontic
therapy.
Conclusion. This comprehensive
search indicates an absence of reli-
able evidence for the positive effects
of orthodontic therapy on patients
periodontal status. The existing evi-
dence does not support the claim
that orthodontic therapy results in
overall improvement in periodontal
health.
The systematic review described here was
funded by the American Dental Association
Foundation, Chicago.
Dr. Chung is a clinical assistant professor, Department of Pediatric Dentistry, College of Dentistry, University of Illinois at Chicago. She also is an evidence
reviewer for the American Dental Association.
Dr. Henwood is in private practice in San Antonio. He also is an evidence reviewer for the American Dental Association. Address reprint requests to Dr.
Henwood at 9240 Guilbeau Road, Suite 128, San Antonio, Texas 78250.
Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

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COMMENTARY
Importance and context. The American Asso-
ciation of Orthodontists (AAO)
1
states in its litera-
ture that dental alignment achieved with ortho-
dontic therapy facilitates plaque removal and
reduces occlusal trauma, which improves manage-
ment of periodontal health. While this AAO publi-
cation suggests that orthodontic therapy may
have an indirect effect by allowing better manage-
ment of periodontal health, on the basis of this
systematic review, we find that a direct positive
association of orthodontic therapy with perio-
dontal health is yet to be demonstrated.
Strengths and weaknesses of the system-
atic review. The review authors used widely
accepted methods to identify studies addressing
the clinical questions posed. They established no
single a priori periodontal outcome measure. The
outcomes evaluated included both patient-
oriented and disease-related measures. The inclu-
sion and exclusion criteria were explained and
reasonable. The authors recognized the reviews
limitations: the low number of included studies,
a variety of measured outcomes and a high risk
of bias.
Strengths and weaknesses of the evi-
dence. The pool of 12 studies constitutes a weak
body of evidence; 11 studies were cohort and
cross-sectional and one was an RCT. The studies
differed in the kind of periodontal outcomes that
were assessed, although there were enough simi-
larities for the investigators to make preliminary
conclusions. Overall, the authors of this review
found little evidence to support any positive
periodontal effects of orthodontic therapy. In fact,
they found some evidence of negative periodontal
effects of orthodontic therapy.
Implications for dental practice. Although
the existing evidence comes from poorly designed
research with a substantial risk of bias, it sug-
gests that orthodontic treatment may slightly
increase the risk of developing periodontal dis-
ease, including alveolar bone loss, periodontal
pocketing and gingival recession. The strongest
evidence in establishing a relationship between
orthodontic therapy and periodontal conditions is
a randomized clinical trial that compared peri-
odontal status among people who had or had not
received orthodontic therapy. The authors stated
that they included RCTs; however, they included
only one, and its relevance as a basis for com-
parison may be questioned. In it, the treatment
lasted only three months, whereas the norm for
orthodontic treatment duration is 12 to 18 months.
Further research is needed to assess the associa-
tion between orthodontic therapy and periodontal
health.
Critical Summaries is supported by grant 1 G08 LM008956-01A2
from the National Library of Medicine and the National Institute of
Dental and Craniofacial Research.
These summaries, published under the auspices of the American
Dental Association Center for Evidence-based Dentistry, are prepared
by practitioners trained in critical appraisal of published systematic
reviews who work under the mentorship of experts. The summaries are
not intended to, and do not, express, imply or summarize standards of
care, but rather provide a concise reference for dentists to aid in under-
standing and applying evidence from the referenced systematic review
in making clinically sound decisions as guided by their clinical judg-
ment and by patient needs.
For more information on the evidence quality rating provided above
and additional critical summaries, please visit http://ebd.ada.org.
1. American Association of Orthodontists. Want a beautiful smile? St.
Louis: American Association of Orthodontists; 2006.
RESEARCH CRITICAL SUMMARIES
576 JADA, Vol. 140 http://jada.ada.org May 2009
Copyright 2009 American Dental Association. All rights reserved. Reprinted by permission.

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