*2.4.4 Respiratory diseases*

Recent reports advocate that bacteria from oral cavity can be accountable for many respiratory diseases like aspiration pneumonia [19]. There is a chance for Pedodontists and Periodontists to promote impressive and useful methods to prop up oral health in children and young people with chronic obstructive pulmonary disease (**Figure 3**).

**Figure 3.** *Periodontal disease as a risk factor for systemic condition.*

#### *Interdisciplinary Periodontics DOI: http://dx.doi.org/10.5772/intechopen.99265*

It is becoming more evident that there is a direct link between periodontal health and general health. Identifying oral health problems during early childhood would draw a preventive attention on periodontal tissues. Keeping this in mind pedodontist and periodontist can work cohesively to ameliorate durable oral health outcomes for children and adolescents.

#### **2.5 Ortho–perio synergy**

The term 'synergy' refers to two or more distinct influences or agents acting together to create an effect greater than that predicted by knowing only the separate effects of the individual agents. This definition is applicable to the classic relationship between orthodontics and periodontics specialities in treating patients [20, 21]. No matter how talented an orthodontist is, a magnificent orthodontic correction can be destroyed by a failure to recognise periodontal susceptibility.

The interrelationship between Orthodontics and Periodontics often resembles symbiosis [22]. In many cases, periodontal health is improved by orthodontic tooth movement, whereas orthodontic tooth movement is often facilitated by periodontal therapy. A multidisciplinary approach is often required for the correction of complex dentoalveolar problems in patients and this can be better explained by ortho-perio integration.

Periodontal disease is not necessarily a contraindication to orthodontic treatment provided that the condition has been stabilised; however loss of alveolar bone and soft tissue architecture may pose considerable challenges to oral rehabilitation. It has been suggested that adjunct orthodontic treatment may play an important role in developing the optimal base needed for re-establishing an aesthetic and functional dentition in these cases.

Orthodontic patients can be classified into three categories-


Patients belonging to the second category needs a multi-disciplinary approach requiring periodontist and orthodontist. For treating these type of patients both specialists should be called for during treatment planning and follow up management.

#### *2.5.1 Evaluation of orthodontic patients for periodontal problem*

Though bleeding on probing is usually a sign of active periodontal disease, on a practical note absence of bleeding on probing is a superior foresee criteria of periodontal health. In other way, even though there is presence of pocket depth, an absence of bleeding on probing can be used as a test of healthy gums. Bleeding on probing is usually checked by inserting a graduated metallic or plastic probe into gingival sulcus at an agreeable range of force between 10 to 20 gms. Patients requiring orthodontic treatment or under active orthodontic therapy should be informed of this persistent bleeding on probing and should be cautioned that they are at risk of periodontal disease and thus they need to consult a periodontist.

Researches have indicated the gravity of complete periodontal examination with a graduated periodontal probe, 6 sites per tooth for an extensive interpretation of periodontal status mostly bleeding on probing and probing pocket depth in orthodontic patients [23, 24].

#### *2.5.2 Orthodontic treatment and its effect on periodontium*

It has been widely believed that appropriately applied orthodontic forces do not damage the periodontium. However, insufficient width of attached gingiva is widely believed to be a predisposing factor for gingival recession. Orthodontic treatment and retention phase may be a risk factor for labial gingival recession. After orthodontic treatment with fixed appliance, the incidence increases from 7% at the end of treatment to 20% at 2 yrs. after treatment and to 38% at 5 years after treatment [25]. Alveolar bone dehiscence is also a predisposing factor for gingival recession.

Steiner et al. suggested that tension in the marginal tissue created by the orthodontic forces could be an important factor in causing gingival recession. Thickness of gingival tissue (Gingival biotype) at pressure side is an indicator of possible gingival recession [26].

Greenbaum et al. studied the effects of slow and rapid maxillary expansion on periodontium*.* They concluded that patients subjected to rapid maxillary expansion showed significantly lesser bone relative to the cementoenamel junction when compared to patients treated with slow expansion [27].

Erkan et al. observed that gingival margin and mucogingival junction moved in the same direction along with teeth when orthodontic intrusion is done. Extrusion also produces gingival margin and mucogingival junction movement in same direction as the extruded teeth resulting in reduction of sulcus depth without reduction in the width of attached gingiva [28].

#### *2.5.3 Orthodontic treatment as an adjunct to periodontal therapy*

Various orthodontic treatments such as up righting, intrusion and rotation are performed to correct pathologically migrated teeth that control further periodontal breakdown, improve oral function and provide acceptable aesthetics. These procedures should be performed only after stabilising active periodontal disease.

Despite of inconsistent relation between malocclusion and periodontal disease, connection of crowded or malposed teeth permit the patient better access to clean all the surfaces of his/her teeth. Food impactions are also reduced or eliminated by the creation of proper arch form and proximal contact [29, 30].

Orthodontic uprighting of the tilted molars has several advantages: the distal movement of teeth allows the deposition of alveolar bone on the mesial defect, thereby eliminating the gingival folding and plaque retentive area on mesial side [31].

Orthodontic extrusion of teeth may be indicated for shallowing out intraosseous defects and for increasing the clinical crown length of single rooted teeth. Orthodontic intrusion has been recommended for teeth with horizontal bony defect or infrabony pockets [32].

The hemiseptal defects or one wall defect can be eliminated using uprighting, extrusion and levelling of the bone defect [31]. Bodily movement of the tooth into an intrabony defect has been believed to carry the bone along with the tooth, that results in improvement of defect. This will ameliorate neighbouring tooth position prior to placing implant or replacing the tooth. If the tooth is supraerupted with osseous defect, intrusion and levelling of the bony defect can help to eliminate these problems.

Deepa outlined the utility of orthodontic soft aligners in relocating a periodontally compormised tooth. Light and intermittent forces generated by the soft aligner allow regeneration of tissue during tooth movement [33].

Complaisance of patient, encouragement and oral hygiene maintenance will facilitate to identify the perfect time to initiate adjunctive orthodontic treatment. If enough confirmation of complete resolve of inflammation is achieved then orthodontic treatment can be started six months after active periodontal therapy.
