Orthodontic Risk Factors ORA

IDRA*/ORA Classes ratio

 

 

O.P.R.A The Orthodontic-Periodontal Risk Assessment

 

 

 

Introduction

To date, there are no clear references in the literature describing when orthodontic therapy can be performed in patients with a history of periodontitis. We only have one certainty: orthodontic therapy should only begin when the periodontal patient has been successfully treated.

This means that the patient affected by periodontal disease will first undergo all procedures outlined in the guidelines for periodontal treatment, aimed at restoring health conditions, and only then can orthodontic therapy begin. Obviously, due to the chronic nature of periodontal disease, it is essential that periodontal biometric parameters are continuously monitored during tooth movement.

Furthermore, the literature does not provide precise indications on how to proceed orthodontically to reduce the risk of periodontal relapse. We can only draw a series of deductions from the interpretation of the basic rules of tooth movement regarding Intensity, Direction, and Duration of movement, which suggest which movements can be performed with greater safety and which with less safety.

In this regard, the authors of the OPRA article (M. Musilli, S. Lee, M. Farella, G. Paolantoni), based on these critical issues, have developed a graph that highlights the orthodontic factors most likely to increase the risk of periodontal relapse. They assign, albeit arbitrarily, a risk gradient to each of the parameters examined, useful for visualizing the incidence of these factors in a simple way.

The greater or lesser risk of favoring periodontal disease relapse represented by the orthodontic device itself becomes increasingly important in relation to the severity of the patient's periodontal diagnosis (Stage and Grade).

The graphs on this site are inspired by the OPRA article (M. Musilli, S. Lee, M. Farella, G. Paolantoni: The Orthodontic-Periodontal Risk Assessment (OPRA) in developing Periodontal Disease. Ann Stomatol 2020; XI (1-4): 16-27).

Objective

The objective of this work is to help clinicians visualize, through a simple geometric diagram, the risk of periodontal relapse in treated patients undergoing orthodontic therapy, after entering the periodontal patient's data in assisted mode.

As a result, the periodontist, hygienist, and orthodontist can together define the most appropriate solutions in terms of devices, orthodontic and periodontal strategies, and the frequency of monitoring periodontal health conditions during the orthodontic phase.

References

In the reference article for OPRA, regarding the recommendations expressed by international authors, three main areas are highlighted related to the ORTHODONTIC DEVICE , the LOAD exerted by the device, and some PERIODONTAL ASPECTS related to the MOVEMENT planned by the orthodontic device  itself. These three areas include the fundamental aspects of orthodontics most closely connected to the biological stimuli that impact periodontal health conditions. Within these areas, the authors have identified five specific aspects of orthodontic therapy, without clear boundaries, closely linked to the fixed appliance applied, which can influence periodontal conditions depending on the patient's susceptibility: 1. REDUCTION in the use of dental anchorage. 2. CLEANABILITY of the device. 3. PRESUMED DURATION of therapy. 4. ACCURACY of the force system expressed by the orthodontic device. 5. PLANNED DIRECTION OF MOVEMENT in relation to the position of the basal bone.

Regarding the DEVICE già as early as 2006, Narajo highlighted changes in the subgingival microbiota three months after the application of fixed orthodontic devices. Marsh, in 2017, observed a worsening of the virulence of the microbiome over time. Finally, many authors, including Melsen, as written in her 2012 book Adult Orthodontics, emphasized that the orthodontic device, in the presence of bacteria-induced inflammation, could result in attachment and alveolar bone loss. These observations push us to use easily cleanable orthodontic devices, avoid unnecessary movements, and perhaps even avoid applying the device to groups of teeth that we do not intend to move, reduce the duration of movements and the presence of attachments as much as possible, and preferably use skeletal anchorage (the factors involved in this area are the first, second, and third).

Regarding LOAD, Jepsen in 2021 recommended light forces. Several authors, including Nikolai (1985), Verna, and Bassarelli (2019), have demonstrated that only correct biomechanics can distribute the forces applied by the orthodontic appliance over the entire root surface, avoiding concentration in very limited regions (such as the alveolar crest or root apex), which could lead to ischemia and tissue damage. Other authors, including S. Chaushu in Chapter 13 of The Ortho-Perio Patients by Eliades and Katsaros (2019), hypothesize that orthodontic forces can aggravate periodontal suffering through the intensification of periodontal inflammatory stimuli. All these hypotheses suggest that the load on the periodontium applied by the orthodontic appliance must be dosed with extreme care and for the strictly necessary time, especially when the periodontal conditions expressed by the STAGE of the disease and the susceptibility to periodontal disease expressed by the GRADE are high (the factors involved in this area are the third and fourth). .

Regarding the PERIODONTAL ASPECTS related to TOOTH MOVEMENT, orthodontic literature has long highlighted the importance of avoiding excessive movement of teeth in the vestibular or lingual direction away from their basal bone (Tweed 1936) to prevent progressive demineralization of the alveolar bone (Melsen 2011). This issue has become increasingly relevant, leading to the definition of Alveolar Bone Housing as a spatial entity beyond which one should not extend. Although this direction of movement, as described in the literature ( Vassalli et al., 2010 systematic review ), is associated with the risk of gingival recession, especially in the presence of a thin periodontal  phenotype rather than periodontitis, it can lead to demineralization of one or more alveolar walls over time. Demineralization not only constitutes the disappearance of a natural physical barrier around the root but also the loss of a containment element for the occlusal and functional stability of the teeth, which could make a difference in case of recurrence or relapse of periodontitis. For this reason, the authors have included it among the factors to be monitored.

From a risk assessment perspective, it would certainly be more useful to know the thickness of the alveolar bone in relation to the movement, but it is not ethically possible to routinely request a three-dimensional radiographic examination  (CBCT).  For this reason, although there is no strong evidence, reference can be made to the article by Zweers J et al. (2014), which describes a moderate association between vestibular gingival thickness and the underlying alveolar bone. This area contains references and suggestions regarding the orthodontic device, both in terms of the accuracy of the force system (excessive and poorly distributed forces can rapidly demineralize the bone surrounding the teeth and create jiggling movements with consequent tissue disorder if accompanied by occlusal trauma) and the direction of tooth movement, which should be as close as possible to the basal bone, especially in the presence of a thin gingival phenotype.

How the Page is Structured

On this web page, we will find the first five questions related only to the orthodontic device and the planned movements, followed by an additional question about the Stage and Grade of the treated periodontal patien . For simplification, the Stage and Grade have been grouped into a value scale as indicated in the article by Heitz-Mayfield (2020)  regarding the definition of the risk of Implant Disease Risk Assessment (IDRA)

The first five answers will be used to create a POLYGON that REPRESENTS   the POTENTIAL RISK posed by orthodontic therapy in general. Each of the values represented by the five questions constitutes an orthodontic risk factor, also indicated in the literature, and the mathematical average of these values helps us calculate the Average Orthodontic Risk. Subsequent studies may assign different weights to the individual values examined for the composition of this radar chart, suggesting a weighted average rather than a mathematical average. The last question serves to correlate the patient's periodontal health conditions with the average risk posed by the planned orthodontic device.

Conclusions

Through these graphs, it is possible to immediately visualize the potential risk to which a periodontal patient undergoing orthodontic therapy is exposed. In this way, clinicians can decide whether to modify the orthodontic objectives, change the characteristics of the device itself, or determine the frequency with which to monitor the patient's periodontal health conditions throughout the orthodontic therapy phase.

Compared to the 2020 OPRA article, it was preferred to refer to two separate graphs to better express and represent the risk factors related to the orthodontic device and the actual risk that these factors may reactivate a new phase of periodontitis in susceptible patients.

Bibliography

1. M. Musilli, S. Lee, M. Farella, G. Paolantoni: The Orthodontic-Periodontal Risk Assessment (OPRA) in developing Periodontal Disease. Ann Stomatol 2020; XI (1-4): 16-27
2. Naranjo, A.A.; Triviño, M.L.; Jaramillo, A.; Betancourth, M.; Botero,  J.E.  Changes  in  the  subgingival  microbiota  and  periodontal  parameters  before  and  3  months  after  bracket  placement.  Am  J  Orthod  Dentofacial  Orthop  2006,  130,  e17–e22.
3.  Marsch P.D., Laura E. Dental biofilm: ecological interactions in health and disease.
4. J Clin. Periontol. 2017;44 (supply.18):S12-S22.
5. Cattaneo  PM,  Treccani  M,  Carlsson  K,  Thorgeirsson  T,  Myrda A, Cevidanes LHS, Melsen B: Transversal maxillary dento-alveolar  changes  in  patients  treated  with  active  and  passive self- ligating brackets: a randomized clinical trial us-ing  CBCT-scans  and  digital  models  Orthod  Craniofac  Res  2011;14:222–233
6. Melsen B. Adult orthodontics. 1st ed. UK: Wiley-Blackwell; 2012
7. Jepsen, K., et. Al. “The effect of timing of orthodontic therapy on the outcomes of regenerative periodontal surgery in patients with stage IV periodontitis: A multicenter randomized trial. Journal of Clinical Periodontology 2021
8.  Nikolai R.J. Bioengineering Analysis of Orthodontic Mechanics. Philadelphia: Lea
9. & Febiger, 1985. P 156-157.
10.  Chackartchi T. Chaushu S. Stabholz A. Orthodontic Treatment in Patients with Severe Periodontal Disease;
11. In Eliades, T., Katsaros C., (ed); The Ortho-Perio Patient: Clinical Evidence &
12. Therapeutic Guidelines Quintessence Publishing Co, Inc 2019: 192
13. Verna C. Bassarelli T. Orthodontic Mechanics in Patients with Periodontal Disease;
14. In Eliades, T., Katsaros C., (ed); The Ortho-Perio Patient: Clinical Evidence &
15. Therapeutic Guidelines Quintessence Publishing Co, Inc 2019: 176-179
16. Tweed CH. The application of the prin- ciples of the edge-wise arch in the treat- ment of class II, division 1, malocclu-sion: part I. Angle Orthod 1936;6:198–208
17. Nokhbehsaim,  M.;  Deschner,  B.;  Winter,  J.;  Reimann,  S.;  Bourauel, C.; Jepsen, S.; Jäger, A.; Deschner, J. Contribution of orthodontic load to inflammation-mediated periodon-tal destruction. J Orofac Orthop 2010, 71, 390–402
18. Joss-Vassalli I, Grebenstein C, Topouzelis N, Sculean A, Katsaros C. Orthodontic therapy and gingival recession: a systematic review. Orthod Craniofac Res. 2010 Aug;13(3):127-41. 
19. Fu, J.-H., Yeh, C.-Y., Chan, H.-L., Tatarakis, N., Leong, D.J. and  Wang,  H.-L.  (2010),  Tissue  Biotype  and  Its  Relation  to  the  Underlying  Bone  Morphology.  J  Periodontol.  2010  Apr;81: 569-574.
20. Heitz-Mayfield dek 2020 (Heitz-Mayfield LJA, Heitz F, Lang NP. Implant Disease Risk Assessment IDRA–a tool for preventing peri-implant disease. Clin Oral Impl Res. 2020;31:397–403

For information on additional bibliographic sources, refer to the bibliography of the first cited Article.