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Iatrogenic effects of orthodontic treatment
Orthodontics is an essential aesthetic treatment that patients seek in order to enhance their selfconfidence, yet it may cause unwanted issues if it wasn’t properly treated, It can affect the
periodontal tissues, pain, root resorption, hypersensitivity, pulpal reaction, mobility, traumatic
ulcerations, damage to the enamel surface, and alveolar bone loss.
Adverse effects to the periodontal tissues
1. Gingival inflammation
The presence of plaque is the most common
cause of gingivitis and periodontitis, there are
many factors that can induce gingivitis in
cases of orthodontic treatment as the poor oral
hygiene of the patient as the patient may find
it difficult to brush their teeth in the presence
of the orthodontic treatment , also chemical
irritation by materials used for bonding ,
mechanical irritation by bands and food
impaction. However with good oral hygiene
patients , gingival irritation may yet appear yet
it is transient that doesn’t cause attachment
loss. Gingival hyperplasia can cause pseudo
pockets which is self-limiting , within weeks
of debanding. Attachment loss Plaque and the
mechanical irritation caused by the band or the cement, poor oral hygiene are the
etiologic factors for attachment loss.
Potential adverse affect to the teeth
1. Root resorption
it is a common adverse effect which is called orthodontic-induced root resorption
,It usually affects 1-2 mm of the apical part of the tooth , it begins as surface
resorption or initial inflammation. The root apex is the most affected part as the
applied forces are concentrated on the
apex especially when it is applied for long
period as a result necrosis of the
compressed periodontal ligaments
happens The leukocytes that migrate out
of periodontal ligaments capillaries has
osteoclast progenitors that coalesce to
form multinucleated cells, capable of
resorbing mineralized tissues (bone and
tooth roots)so it is less mineralized with
more possibility of resorption, Then the
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repair process smoothes over the new root surface and a net loss of root length
occurs. It was found that the maxillary Anterior teeth are subjected more to root
resorption as their anatomy tend to transfer more forces.Also it was found that
intrusion is the most damaging effect, So the orthodontist is required to assess the
root resorption each visit in order to minimize the root loss by CBCT. To prevent
root resorption there should be a gap treatment with intermittent forces that allows
the resorbed cementum to restore .
2. Hypersensitivity
There are 2 forms of allergy that could
occur either intraoral or extraoral .The
nickel present in the bracket band and the
wires are responsible for allergy in some
patients, the reactions might range from
ulceration, erythematous lesions, or even
anaphylactic shock, depending on the
patient. titanium wires and brackets were
the most inert and can be used intra-orally
in a corrosive environment, if nickel
titanium must be used it should be epoxy
coated. The second allergy comes from
latex gloves.
3. TMJ problems
evidence indicates that orthodontic treatment performed during adolescence
generally does not increase or decrease the odds of developing TMJD later in
life. Also achieving stable occlusion doesn’t necessarily improve TMJ. So
there is no evidence to support the theory that orthodontic treatment causes
TMD or cures it , however history should be taken from the patient if there’s
previous TMJ problem and whether it increased during the treatment or it
didn’t
4. Pulpal reaction
Studies released that the blood flow in the pulp decreases during treatment the
increases after to reach the peak at 7 days after the application of force , those
forces induce vascular changes which are inflammatory. However the
inflammation and the feeling of discomfort is temporary which resolve within a
week. Luckily ,pulp vitality loss is rare. In order to reduce the risk of pulpal
reaction reduce the forces and use small archwire and to decrease the pulpal pain
the patient can use chewing gums or wafers to disrupt the compressive forces
from the orthodontics and giving an intermittent blood flow to the periodontal
ligaments.
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5. Mobility
Tooth mobility during treatment is normal as a consequence of applying forces to
the teeth , bone resorption could occur which will cause the periodontal ligaments
quadruple in size and becomes 1 mm wide so the teeth have more space to move
in. In addition since gingivitis usually occurs with orthodontics due to the strong
forces applied it makes the tooth more mobile. The most noticeable teeth are the
incisors however moderate mobility occurs when the patient is clenching or
grinding against a tooth that has moved into a position of traumatic occlusion.
Excessive mobility is self resolving which the tooth return back to normal upon
removal of the orthodontics without permanent damage.
6. Traumatic ulcerations
Mucosal trauma is usually common during the
orthodontic treatment and can be caused by many
factors including ulceration by the brackets and
the protruding archwires near the molar region,
chemical burns from the acid-etchant. lingual
appliances tend to ulcerate the tongue and labial
appliances usually ulcerate the buccal or labial
mucosa. In order to avoid traumatic ulceration
by careful instrumentation, and instruct the
patients to use wax to avoid mucosal irritation
from the brackets and gives temporary relief.
7. Pain
studies have shown that 75% of orthodontic patients suffer from pain which may
lead to ceasing the treatment. As it reduces the proprioceptive and discriminating
abilities of the patients for up to 4 days, which result in lowering of the pain
threshold and disruption of normal mechanisms associated with proprioception
input from nerve endings in the periodontal ligaments At the same time, there will
be pressure, ischaemia, inflammation, and edema in the periodontal ligaments
space. stiffer wires can cause a higher peak pain level however ,heat activated
nickel titanium causes lesser pain. So the dentist should encourage the patient to
use chewing gum containing aspirin to relief the pain and can prescribe Ibuprofen.
8. Damage to tooth enamel surfaces
The evidence released that orthodontic
patients are at higher risk to caries and
decalcification it appears as a white spot
lesion which is mostly due to poor oral
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hygiene, it has a rapid rate during the first 6 months then it
develops at a slower rate.Furthermore, since saliva has a
protective role against white spot lesion so the maxillary
teeth are more susceptible than mandibular. In order to
prevent by maintaining proper hygiene, by fluoride tooth
paste and xylitol. Improper de-bonding especially when the
strength of the micromechanical bond between enamel and
the bonding resin exceeds the cohesive strength of the
enamel which will lead to cracks in the enamel. It was found that ceramic brackets
are more liable to cause enamel fracture So they can provide stagnation areas to
develop caries, as a result partial tooth fracture or discoloration. For prevention ;
the brackets should be removed by electro-thermal or laser to dissolve the cement
and the safest way is to distort the brackets.
9. Alveolar bone loss
Multiple studies have shown changes of alveolar bone density due to active boneremodeling through orthodontic treatment , the bone density decreases due to
resorption of pre-existing bone tissue and formation of new bone tissue through
bone remodeling. As the new bone tissue has less mineral content than the preexisting bone tissue. However luckily it is not found aggressively over patients if
found it ranges from 0.5 to 1 mm.
10. Risk of Radiation exposure
Xrays are an essential diagnostic procedure for orthodontic yet it has multiple
adverse effects on the patients especially if they were exposed to multiple
radiations. Therefore ,we should minimize radiation as much as possible , to be
only used when necessary and for pregnant women we must use a lead apron .
Bibliography
Anusha S1, N. N. (2021). Iatrogenic Effects of Orthodontic TreatmentA Review. International Journal of
Current Research and Review.
Kim, H. H.-G. (2012). Effects of orthodontic treatment on human alveolar bonedensity distribution. clin
oral invest.
Meeran, N. A. (2013 ). Iatrogenic possibilities of orthodontic treatment and modalities of prevention.
journal of orthodontic science .
Talic⁎
, N. F. (2011). Adverse effects of orthodontic treatment: A clinical perspective. Saudi Dental .
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MCQ
1)what is the safest way to remove the brackets
A) forcefully pulling it out
B)Laser removal
C) Distort the brackets
D)Electrothermal
2) Main cause of allergy in orthodontic patients
A)Latex gloves
B) Nickel
C)Acid-etch
D)Bond
3)Duration of pain the patient can feel is
A)A month
B) A week
C) 4 days
D) 1 day
4) what is the most affected part of the tooth from the forces
A)The enamel
B) The dentin
C)The pulp
D) The root apex
5) How can the patient relief traumatic injury
A) Wax
B)Ibuprofen
C) massage
D) chewing gum
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