Received: 20 May 2019 Revised: 5 August 2019 Accepted: 11 August 2019
DOI: 10.1002/JPER.19-0306
C O M M E N TA RY
Orthodontic treatment in periodontal patients: The use
of periodontal gold standards to overcome the “grey zone”
Giovan Paolo Pini Prato1 Leandro Chambrone2,3,4
1 Tuscany Academy of Dental Research (ATRO), Florence, Italy
2 School of Dentistry, Ibirapuera University (Unib), São Paulo, Brazil
3 Unit of Basic Oral Investigation (UIBO), School of Dentistry, Universidad El Bosque, Bogota, Colombia
4 Department of Periodontics, College of Dentistry and Dental Clinics, The University of Iowa, Iowa City, IA, USA
Correspondence
Prof. Leandro Chambrone, Rua da Moóca, 2518 Cj. 13 03104-002 São Paulo, SP, Brazil.
Email: leandro_chambrone@hotmail.com
1 GENERAL COMMENTS
Is it safe to submit periodontitis patients to orthodontic
therapy? This is certainly one of the most striking questions
during the decision-making process shared by both periodon-
tists and orthodontists. A recent survey demonstrated that the
majority of patients with moderate-to-severe periodontitis
(68%) showed interest in orthodontic therapy because of
esthetical and functional changes caused by pathologic tooth
migration.1 A comprehensive search on PubMed focusing
on “ortho-perio treatments” (i.e., entry terms: orthodontic
AND periodontal treatment; orthodontic AND periodontal
AND treatment) identified >2900 articles published in the
literature on this interdisciplinary approach. However, the
majority of these articles are experimental studies on animal
models2–5 and case series,6–14 with some controlled clinical
trials are available.15,16
Although it is expected that any orthodontic treatment
should initiate after the complete healing of previously
inflamed/diseased periodontal tissues, the literature remains
unclear (and somehow controversial) on the exact/best
moment to start tooth movement after periodontal ther-
apy: immediately after scaling and root planing,15 1 to
2 weeks,5–10 2 to 6 months,11,15 or 8 to 12 months13,14 after
active periodontal therapy. Conclusive answers to this and
other chief queries continue to be unclear, demonstrating that
“a grey zone” remains/exists in the orthodontic treatment
of periodontally compromised patients. This issue requires
additional clarification, especially in light of the new con-
cepts of ‘personalized medicine,’ or in other words, the need
J Periodontol. 2019;00:1–5. wileyonlinelibrary.com/journal/jper
for developing treatment strategies based on the patient, and
not just on the tooth or mouth.17,18
2 P ERIO DO NTA L HEALING
V E R S U S B E ST T I M I NG FO R TOOT H
M OV E M E N T
It has been recognized by ‘classic periodontal literature’ that
periodontal tissue stability after therapy may vary according
to the different treatment approaches. For instance, healing
events after non-surgical periodontal therapy were studied
by Badersten et al.19 in patients with severely advanced
periodontitis. After scaling and root planing (i.e., instru-
mentation), there was a gradual and noticeable improvement
of periodontal parameters (i.e., probing depth reduction
and attachment level gain) over the course of 9 months. No
additional changes occurred during the remaining 12 months
of the experimental period. Lindhe et al.20 evaluated the
effect of wound healing after surgical (modified Widman
flap) and non-surgical (scaling/root planing alone) treatment
modalities in patients with advanced periodontitis. It was
observed that improvements regarding gingival condition,
probing depth, and attachment levels obtained for both treat-
ment modalities at 6 months after active treatment remained
unchanged during the maintenance care period.
With respect to regenerative and soft tissue augmenta-
tion procedures, final healing stability may require a longer
period of time to obtain. Cortellini and Tonetti21 stated that
after guided tissue regeneration procedures, probing or deep
© 2019 American Academy of Periodontology 1
2 PINI PRATO AND CHAMBRONE
scaling in the treated area is generally avoided before the
1-year follow-up visit. Agudio et al.22 in a long-term study
evaluating high level oral hygiene patients treated with
gingival augmentation procedure (i.e., free gingival graft)
demonstrated that the gingival margin and increased ker-
atinized tissue band appeared stable 1 year after surgery.
Similarly, Pini Prato et al.23 evaluated the achievement of
complete root coverage of 386 recessions using four differ-
ent root coverage procedures (i.e. free gingival graft, coro-
nally advanced flap, connective tissue graft, and guided tis-
sue regeneration). The authors reported that at the 1-year
follow-up time, the healing phase may be considered to be
complete.
Based on the findings of these studies, it can be argued that
the healing process, in terms of true anatomical-functional
outcomes, appeared to be completed up to 1 year after
surgery.19–23 However, orthodontic therapy is often initiated
during the initial/early phase of periodontal healing (i.e., <2
months after basic procedures/surgical therapy), and thus
the key question remains unanswered: Wouldn’t it be bet-
ter if orthodontic treatment rationale is based on the time
required for the completion of periodontal tissue wound
healing?
3 ‘PERIODONTA L A LGORITHM’
FOR TO OT H M OV E M E N T
The decision-making process for orthodontic therapy of peri-
odontally compromised patients needs to be personalized
according to the particular periodontal therapy/procedures
applied for the establishment of a clinically healthy periodon-
tium. In light of this premise, the following additional queries
should be accounted for as well.
3.1 How does one define a periodontal status
that is acceptable for orthodontic treatment of
periodontitis patients?
Both the classic and current literature on periodontal treat-
ment clearly indicate the importance of achieving low rates
of full-mouth plaque and bleeding on probing after active
periodontal treatment (scores <25% of sites).24,25 Further-
more, long-term maintenance data of chronic periodontitis
patients show a higher risk of additional attachment loss in
sites which demonstrated bleeding on probing during regular
recall check-ups compared with consistently healthy sites.26
It is expected /recommended that these low scores (i.e., opti-
mal plaque control without clinical gingival inflammation) be
reached and maintained during the entire phase of orthodon-
tic therapy (without these conditions, orthodontic tooth move-
ment should be discontinued).15
3.2 How is the periodontal management
during the orthodontic treatment of
periodontitis patients determined?
Patients with periodontitis requiring orthodontic therapy
should receive regular periodontal maintenance care based
on: 1) oral hygiene instructions and tooth cleaning at
3-month intervals;27 2) periodontal re-examination every
6 to 12 months (i.e., probing depth, clinical attachment
level, recession depth, bleeding on probing, mobility);28
and 3) scaling/root planing during active tooth intrusion.29
Similarly, it is expected that patients continue following
regular maintenance therapy concluding orthodontic therapy
(i.e., orthodontic appliance removal).15 Furthermore, it is
important to highlight that although periodontitis patients
may undergo periodontal therapy, the critical factor is
the outcome of the treatment. It can be argued that both
non-surgical and surgical periodontal treatment may not
always be successful in terms of restoring health (i.e., lack
of overt inflammation and infection). Consequently, the
reassessment/revaluation of the periodontal condition (i.e.,
achieving or not achieving a healthy periodontal status) must
be made at the completion of periodontal treatment. If health
has been restored (albeit on a reduced periodontium) then
orthodontic treatment can proceed. Otherwise, orthodontic
treatment should not commence and further re-treatment
should be undertaken until periodontal health is attained. In
rare cases, healthy periodontal status may never be attained
and thus orthodontic treatment would not be recommended.
3.3 When is the proper time to start
orthodontic therapy after periodontal
treatment?
Taking into consideration the healing dynamics of the peri-
odontium according to the different modalities of periodon-
tal therapy, it is recommended that orthodontic therapy start
following: 1) 3 to 6 months after non-surgical/surgical peri-
odontal treatment;19,20 and 2) 9 to 12 months after regenera-
tive surgical procedures.21
3.4 What is the clinical or biologic efficacy of
the orthodontic treatment?
It is expected that the adjunct orthodontic therapy could not
only lead to a realignment of teeth affected by pathologic
tooth migration, but also promote better stability of the peri-
odontium in terms of balancing occlusal forces transmitted
to the alveolar bone and improving the quality of life for
periodontitis patients (i.e. improved chewing mechanics;
self-confidence). On one hand, sites with horizontal bone loss
after periodontal therapy will not be negatively influenced
by the type of tooth movement once the individualized
orthodontic mechanics are established (i.e., an appropriate
PINI PRATO AND CHAMBRONE 3

ratio force/% remaining periodontal support).3,29 In fact,

animal and clinical studies demonstrated that a healthy peri-
odontium with reduced height has a capacity similar to that
of a normal periodontium to adapt to traumatizing occlusal
forces.30 On the other hand, the efficiency of orthodontic
tooth movement in sites with vertical bone loss (i.e., angular
bone defects) deserves additional attention: 1) tooth move-
ment into/through inflamed angular bone defects enhances
the rate of periodontal destruction; 31,32 2) after complete
elimination of subgingival infection, orthodontic tooth move-
ment into infrabony pockets does not produce detrimental
effects, but no coronal gain of attachment is realized as well
(i.e., a long junctional epithelium will be formed without
changes in the periodontal ligament attachment level);31 3)
orthodontic intrusion at healthy sites can lead to new cemen-
tum formation and new collagen attachment, whereas for sites
lacking proper oral hygiene, results vary from a moderate new
attachment development to a worsening of the alveolar bone
loss;33 and 4) the intrusion movement should be carefully
planned as it can increase the risk of other adverse effects not
desired in patients with a reduced periodontium, such as alve-
olar process reduction and root resorption.34 Consequently,
it is recommended that decision-making (i.e., orthodontic
treatment planning) should be based on the initial periodontal
diagnosis, type of tooth movement required, and the patient’s
cooperation.
Based on these conditions and queries, a personalized
‘periodontal algorithm’ for periodontitis patients requir-
ing orthodontic treatment (Fig. 1) should consider the
following:

1. Need of an interdisciplinary evaluation performed by

the periodontist and the orthodontist to evaluate: a) the
patient’s age; b) the severity of periodontal disease and
extension of attachment loss (i.e., grade/stage); c) the
influence of pre-existing systemic conditions; and d)
the patient’s lifestyle and compliance with the proposed
combined therapies.
2. Knowledge on wound healing according to the type of
periodontal therapy the patient received (i.e., non-surgical
or surgical treatment, regeneration): a) 3 to 6 months for
scaling/root planing alone; b) 6 to 9 months for open flap
debridement; and c) 1 year for regenerative approaches.
3. Achievement of periodontal health before beginning
orthodontic treatment (i.e., the decision-making of when a
patient is deemed stable for orthodontic therapy should be
individualized according to the periodontal treatment the
patient underwent). If periodontal health is not attained,
re-treatment should be considered before any initiation of
tooth movement.
4. Assessment of the effects of orthodontic forces and move-
ments on the reduced healthy periodontium, based on the
FIGURE 1 Periodontal-orthodontic treatment algorithm: ‘What
is the time required for periodontal tissues’ wound healing before
starting orthodontic tooth movement?’
severity, extension, and type of periodontal bone loss (i.e,
horizontal/supracrestal bone loss or vertical/angular bone
defects, or furcation involvements). Orthodontic forces
should be balanced/reduced based on the remaining attach-
ment level.
5. Promotion of regular supportive periodontal care (main-
tenance) during the orthodontic treatment. Plaque index
and bleeding on probing rates should be <25%, and
periodontal maintenance intervals must be individualized
according to the initial periodontal diagnosis. The current
periodontitis classification system recognizes that a peri-
odontitis diagnosis should be based on the evidence of loss
of clinical attachment level (at two non-adjacent teeth) and
the presentation and aggressiveness of the disease by stage
(I, II, III, and IV) and grade (A, B, and C).35 Thus, Stage
I and II periodontitis patients (i.e., those with interdental
4 PINI PRATO AND CHAMBRONE
attachment loss <5 mm and radiographic bone loss ≤1/3
of root length) displaying a slow to moderate rate of
progression and periodontal destruction proportional
to the amount of dental biofilm deposits (Grades A
and B) may follow regular maintenance care appoint-
ments at a 6-month interval. However, Stage III and IV
periodontitis patients and patients with a rapid rate of
destruction/progression (Grade C) should follow a shorter
maintenance interval (3 to 4 months).
6. Joint periodontal and orthodontic evaluation of the final
outcomes: a) maintenance of the clinical attachment levels
accomplished by periodontal therapy; and b) achievement
of proper tooth alignment based on the patient’s periodon-
tal tissue attachment limitations.
Despite the vast amount of literature published over many
decades, many periodontitis cases still call on our intuitive
clinical decision-making skills to determine proper timing
and therapy execution. Future directions in how these cases
are evaluated and managed (i.e., implications for research
and practice) may also include the use of other diagnos-
tic tools for the evaluation of dentoalveolar relationships
critical to defining risk assessment in periodontitis patients
requiring orthodontic therapy, such as cone-beam computed
tomography imaging.36 As recently pointed out by one of
the 2017 American Academy of Periodontology Best Evi-
dence Consensus papers that evaluated dentoalveolar bone
changes promoted by orthodontic tooth movement using this
technology:35 1) cone-beam computed tomography allows
for a precise assessment/diagnostic acumen of alveolar bone
dimensions (i.e., buccal bone plate thickness and height and
detection of bone dehiscences), improving decision-making
and helping to prevent the development of iatrogenic seque-
lae; and 2) the use of this diagnostic tool may be considered for
patients with a thin periodontal phenotype before treatment
(especially the anterior mandible and maxillary premolar
region), as they are at an increased risk of developing addi-
tional periodontal tissue loss.35 In addition, it is always impor-
tant to highlight that strong collaboration with the treating
orthodontist and stringent oversight is critical in managing the
periodontitis patient with a malocclusion requiring treatment.
4 CONC LU SI ON S
The lack of an accurate ‘gold standard’, a research-based
moment for initiating orthodontic tooth movement after peri-
odontal therapy, demonstrates that: 1) a ‘grey zone’ of evi-
dence on this subject remains despite the advances gathered
by contemporary periodontology; and 2) knowledge on peri-
odontal wound healing dynamics may be considered the best
(i.e., gold standard) ‘biologic starting point’ of orthodontic
treatment for treated periodontitis patients.
ACKNOW LEDGMENTS
The authors would like to thank Dr. Sandra H. Wolf (Depart-
ment of Periodontics, College of Dentistry and Dental Clin-
ics, The University of Iowa) for her assistance during the final
review of this commentary. The authors report no conflicts of
interest related to this commentary.
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How to cite this article: Pini Prato GP, Cham-
brone L. Orthodontic treatment in periodontal patients:
The use of periodontal gold standards to overcome
the “grey zone”. J Periodontol. 2019;1–5. https://doi.
org/10.1002/JPER.19-0306