Estado Periodontal Alineadores
Estado Periodontal Alineadores
Estado Periodontal Alineadores
2019
Original Article
Periodontal health status in patients treated with
the Invisalign® system and fixed orthodontic
appliances: A 3 months clinical and microbiological
evaluation
Luca Levrini1, Alessandro Mangano2, Paola Montanari1, Silvia Margherini1,
Alberto Caprioglio1, Gian Marco Abbate1
1
Department of Morphological and Surgical Sciences,
University of Insubria, Varese, Italy,
Correspondence: Dr. Luca Levrini 2
Oro Cranio Facial Disease and Medicine Research
Email: [email protected] Centre, University of Insubria, Varese, Italy
ABSTRACT
Objective: The aim of this prospective study was to compare the periodontal health and the microbiological changes via
real‑time polymerase chain reaction (PCR) in patients treated with fixed orthodontic appliances and Invisalign® system (Align
Technology, Santa Clara, California). Materials and Methods: Seventy-seven patients were enrolled in this study and
divided into three groups (Invisalign® group, fixed orthodontic appliances group and control group). Plaque index, probing
depth, bleeding on probing were assessed. Total biofilm mass and periodontal pathogens were analyzed and detected via
real‑time PCR. All these data were analyzed at the T0 (beginning of the treatment) T1 (1‑month) and T2 (3 months); and
statistically compared using the Mann–Whitney test for independent groups. Results: After 1‑month and after 3 months
of treatment there was only one sample with periodontopathic anaerobes found in patient treated using fixed orthodontic
appliances. The Invisalign® group showed better results in terms of periodontal health and total biofilm mass compared to
the fixed orthodontic appliance group. A statistical significant difference (P < 0.05) at the T2 in the total biofilm mass was
found between the two groups. Conclusion: Patients undergoing orthodontic treatment with the Invisalign® System show
a superior periodontal health in the short‑term when compared to patients in treatment with fixed orthodontic appliances.
Invisalign® should be considered as a first treatment option in patients with risk of developing periodontal disease.
Key words: Clear aligners, fixed orthodontic treatment, Invisalign, microbiological evaluation, periodontal health
Plaque accumulation can favor the transition How to cite this article: Levrini L, Mangano A, Montanari P, Margherini S,
of the microbial biofilm to a more aggressive Caprioglio A, Abbate GM. Periodontal health status in patients treated
with the Invisalign® system and fixed orthodontic appliances: A 3 months
periodontopathogenic flora in subgingival periodontal
clinical and microbiological evaluation. Eur J Dent 2015;9:404-10.
pockets and the production of proinflammatory
cytokines.[4,5] DOI: 10.4103/1305-7456.163218
Furthermore, microbiological studies revealed of selected bacteria, via real‑time PCR, in adults
significant changes in the bacterial composition undergoing fixed or removable orthodontic therapy
of the subgingival dental plaque, so orthodontic with the Invisalign® system. The modified plaque
treatment may affect the equilibrium of oral index (PI), pocket probing depth (PD), and the
microflora and increase bacteria retention.[7] It has bleeding on probing (BOP) were also evaluated
been shown that treatment with fixed orthodontic during the entire period of treatment by clinical
appliances stimulates the growth of a subgingival assessment.
plaque where some periodontopathogenic bacterial
strains are prevalent such as Porphyromonas gingivalis, MATERIALS AND METHODS
Prevotella intermedia, Bacteroides forsythus, Actinobacillus
actinomycetemcomitans, Fusobacterium nucleatum, and Patient population
Treponema denticola.[8‑10] Seventy‑seven patients, 52 females and 25 males with
a mean age of 24.3 years (range from 16 to 30) were
In contrast, the use of removable orthodontic appliance included in this study referring to the Department of
is able to allow an adequate oral hygiene and reduce Orthodontics of the University of Insubria.
the risk for such negative dental and periodontal
complication.[11,12] Orthodontic treatment should Sixty‑seven patients referred to our clinic for orthodontic
be able to expose the patients to none or limited treatment and were randomly selected to the test
side effects. Along with the risk of root resorption Invisalign treatment group and the fixed appliance
periodontal complications are the most reported to treatment group. A group of ten patients who did not
occur. Periodontal health should be regarded as one need any treatment was used as control group. The
of the success criteria in orthodontic treatment.[13] composition of the three groups is shown in Table 1.
contained (20 μl final volume): 4 mM MgCl2, 1 μM and the fixed orthodontic appliance group. The
of each primer, and 2 μl of DMSO suspension. The periodontal parameters showed worst scores in T2
PCR program was the following: (i) Denaturation compared to T0 and T1 in the fixed orthodontic
at 95°C for 30 s, (ii) 40 cycles of 10 s at 95°C, 10 s appliance group, as well as the total biofilm mass. The
at 50°C, 12 s at 72°C, (iii) melting curve performed Invisalign® group showed a statistically significant
for 10 s at 95°C, 45°C, 95°C. Transition rates were increase in the PI values in the T2 compared to T0.
5°C/s in the 72°C segment, 0.1°C/s in the 45°C Furthermore, no statistically significant differences
segment, and 20°C/s for another step. Fluorescence in the BOP and in the PD were observed.
was detected at the end of the 72°C segment in the
PCR step (single mode), and at the 45°C segment The Invisalign® group showed a statistically significant
in the melting step (continuous mode) in the F1 difference (P < 0.05) between the T2 and T0 in the
channel. During initial optimization of real‑time total biofilm mass with a lower score in the 90 days
reaction, PCR products were analyzed using follow‑up control. In the control group, no statistical
agarose gel and by a melting curve analysis to differences were found between the follow‑up
ensure correct sample product size. The positive controls.
reactions showed 7–90°C Tm peaks. The amount
of bacterial DNA in the samples was calculated At T2 the mean bacterial concentration “C” was
following sequent formula (C = q × 25), C is the final 104,536,026; 2739 and 8187 in the fixed orthodontic,
bacterial concentration (totals or single periodontal the Invisalign® and control group, respectively, being
pathogen) in the specimen; q is the bacterial number significantly lower for the two latter groups. The
calculated interpolating threshold cycle with a mean PD in the fixed orthodontic group; Invisalign®
qPCR standard curve. group and control group at T2 were, respectively,
1.3;1.6;1.7. At T1 the mean PD values were 2.20; 2.75;
Statistical analysis 2.15. At T0 the mean PD values were 2.18; 2.18; 2.15.
To compare the differences of the periodontal At the beginning of the study the mean Little’s Index
indices such as PI, BOP, PD; and the differences score for the Invisalign® group was 2.3 ± 0.3, for the
between the microbiological biofilm in the patients fixed appliances group 2.5 ± 0.4 and for the control
treated respectively with Invisalign ® , fixed group 2.3 ± 0.4.
appliances and control group the Mann–Whitney
test for independent groups was performed. The DISCUSSION
level of significance was set at 0.05. Furthermore,
the Mann–Whitney test was performed to test The present study has described microbiological and
differences between different time‑points in each periodontal changes in two groups of patients treated,
group. The level of significance was set at 0.05. respectively, with fixed appliances and Invisalign®
All statistical analyses were run on the statistical removable aligners. The effect of orthodontic
package SPSS (SPSS 17.0; SPSS Inc., Chicago, appliances on periodontal health has been evaluated
IL, USA). A priori sample size calculation was in many studies.[2,5‑8]
performed with α = 0.05 and a power set at 80%.
A systematic review of the literature about the
RESULTS relationship between orthodontic treatment effect
and periodontal health stated that gingivitis and
The microbiological analyses detected the presence of attachment loss were inconsistent across studies,
A. actinomycetemcomitans only in one patient treated and that there is an absence of evidence supporting
with fixed orthodontic appliances at T1 and T2. positive effects of orthodontic treatment on overall
periodontal health, but many data indicate that
A statistically significant difference (P < 0.05) was orthodontic therapy may result in small detrimental
found between the Invisalign® group and the fixed effects to the periodontium.[1]
orthodontic appliance group in all periodontal
parameters (BOP, PD, and PI) with the Invisalign® Plaque accumulation is the main etiological factor,
group scoring lower values compared to the fixed and gingival inflammation enhances the flowing of
orthodontic appliance group. Furthermore, the gingival crevicular fluids that supply plasma proteins,
total biofilm mass showed a statistically significant which are essential for the growth of proteolytic
differences (P < 0.05) between the Invisalign® group anaerobes.[28]
Our data showed how fixed orthodontic treatment with Karkhanechi et al.[34] A possible explanation can
group resulted in higher plaque accumulation be attributable to easier oral hygiene procedures; the
compared to Invisalign® treatment group. This data are absence of bands, brackets and archwires in the patients
in accordance with our previous study.[19] This result treated with Invisalign® can favor the maintenance of
can be attributable to easier oral hygiene procedures better oral hygiene.[19] A recent systematic review of
favored by a better accessibility in Invisalign® patients. the literature[35] showed how clear aligner treatments
Furthermore, fixed orthodontic devices present have an improvement in periodontal health indexes
more plaque retention sites that potentially lead to compared to fixed orthodontic treatments.
periodontal inflammation.[18]
The overall higher periodontal indices and
A significant increase of PI and BOP was found microbiological results can be attributable to better
in patients treated with fixed orthodontic, but PD compliance in oral hygiene procedures in Invisalign®
index had no significant changes. The increase in group as showed in a previous study. Our results have
biofilm mass was a direct consequence of impeded been confirmed by a recent study.[35] In this study,
oral hygiene procedures. This clearly show how a better compliance to oral hygiene procedures in
patients treated with fixed appliances are more likely patients treated with Invisalign was observed. A main
susceptible to gingival inflammation that eventually difference in our study, is that we did not evaluate
could develop to periodontal disease.[27] the patients’ compliance. As the clear aligners are
removable appliances giving to the patients easy
A recent investigation by Ghijselings et al. [30]
access to all teeth surfaces it can be assumed that
showed how in the long‑term patient treated with
this treatment option should be a first choice in adult
fixed orthodontic appliances have a worsening in
patients and in patients with possible periodontal
the periodontal parameters. On the contrary, the
problems.
microbiological analyses underlined a significantly
difference between the aerobe/anaerobe ratio prior
It is important to stress that a careful hygiene maintenance
and after the treatment. [30] Some clinical studies
of the aligners must be performed in order to control the
reported poor periodontal health and greater loss of
plaque accumulation on the clear aligners.[36]
clinical attachment level in the distal area of the dental
arches in patients treated with fixed orthodontic
One of the limitations of this study, is the short
treatment. These worse data could be the result of poor
follow‑up period, a longer observational time would
oral hygiene in molar regions also due to the presence
be useful for the evaluation of the plaque accumulation
of molar bands, which favor food entrapment.[31]
and the periodontal indices because the change of the
Statistical differences between T0 and T2 of the BOP, PD bacterial flora in patients receiving fixed appliances
and PI were found in the fixed orthodontic treatment take place in the first 3 months.[8,37,38]
group. These results are similar to the one reported by
To our knowledge, this is the first prospective study,
Ristic et al.[29] and by Demling et al.[32] that observed an
increase in the periodontal indices and a modification to compare the periodontal status and the plaque
of the microbiological composition. The change in accumulation via real‑time PCR between fixed buccal
the microbiological composition with the shift of appliances and removable aligners in the short‑term
microbiological flora is due to the food entrapment period. Although periodontal status showed the
that eventually lead to plaque accumulation and worst score in patients receiving the fixed appliance
inflammation. [29] In our study, we performed a treatment, we do not suggest to avoid this kind of
professional cleaning in order to eradicate possibly treatment in adult patients. In fact, not all treatment
periodontal pathogens. A recent investigation using objectives can be achieved with clear aligners.
atomic force microscope by Germano et al.[33] showed Furthermore, there is still uncertainty about the
how periodontitis bacteria have complex glycocalyx long‑term possible negative effect of fixed orthodontic
being also able to co‑aggregate thus improving their appliance on periodontal health.
resistance to antibiotics.
CONCLUSIONS
Decreased plaque level were found in the Invisalign®
treatment group and were associated with better Within the limit of this study, we can state that:
periodontal health indices; these results are in accordance • Patients treated with removable aligners had a
better periodontal health status (PI, PD, BOP) subgingival plaque samples. J Clin Periodontol 2005;32:778‑83.
16. Lau L, Sanz M, Herrera D, Morillo JM, Martín C, Silva A. Quantitative
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• Removable aligners seem to facilitate oral hygiene between two methods for the detection and quantification of
Actinobacillus actinomycetemcomitans, Porphyromonas gingivalis
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• Absence of periodontal pathogenic bacteria in Periodontol 2004;31:1061‑9.
Invisalign® treatment group 17. Jordan C, LeBlanc DJ. Influences of orthodontic appliances on
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• Real‑time PCR analysis detected a periodontopathic 2002;17:65‑71.
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19. Levrini L, Abbate GM, Migliori F, Orrù G, Sauro S, Caprioglio A.
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Financial support and sponsorship 20. Alfuriji S, Alhazmi N, Alhamlan N, Al‑Ehaideb A, Alruwaithi M,
Nil. Alkatheeri N, et al. The effect of orthodontic therapy on periodontal
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Conflicts of interest anterior alignment. Am J Orthod Dentofacial Orthop 1975;68:554‑63.
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severity. Acta Odontol Scand 1963;21:533‑51.
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