Dans le document Inflammatory side effects associated with orthodontic tooth movement (Page 88-107)

Orthodontic tooth movement is induced by mechanical stimuli and facilitated by remodeling of the periodontal ligament and alveolar bone. The remodeling activities and the ultimately tooth displacement are the consequence of an

inflammatory process. The cellular, biochemical and molecular events that take place during orthodontic tooth movement have been extensively studied. Although

inflammation is essential in the remodeling activities, it may result in several

undesirable side effects. Thus, not only the aesthetic and functional outcome but also the adverse events for the teeth and the supporting tissue related to the orthodontic tooth movement should be considered.

Orthodontic treatment is very often associated to gingival inflammation, as a result of the local change in the microbial ecosystem and in the composition of the bacterial plaque. Patients with good oral hygiene may develop gingival inflammation during orthodontic treatment. Mild to moderate gingivitis with bleeding on probing and gingival enlargement is evident, especially when fixed orthodontic appliances are used (45-48). Gingivitis does not progress into periodontitis, in terms of loss of attachment and bone probably due to the restriction of plaque-induced inflammatory reaction in the supra-alveolar connective tissue. According to Zachrisson and

Zachrisson (40), 90% of patients acquired little or no periodontal breakdown during orthodontic treatment with fixed appliances, emphasizing the importance of repeated motivation and instructions of oral hygiene. The local changes in the oral ecosysrem and the development of gingivitis during orthodontic treatment are reflected in

changes in the composition of GCF (166, 167). The group of cytokines has attracted particular attention as their levels may increase rapidly with plaque accumulation and before the subsequent visible clinical inflammation, suggesting that they may have a potential role as early markers of gingival inflammatory changes (166). In the studies described in this Thesis on experimental tooth movement (chapters 6 and 7), no significant changes were observed on any of the clinical parameters during the whole experimental period. This is mainly due to the oral hygiene instructions given to each patient before and during the experimental treatment. In fact, meticulous plaque control and motivation for oral hygiene took place every week for all patients. This

allowed our research to focus on the mechanically induced inflammation within the bone and periodontal ligament. Although a weekly visit does not represent a common procedure, orthodontic patients should be aware of the importance of reaching high hygiene levels during orthodontic treatment. Furthermore, for the

clinician it is important to identify patients at risk for periodontal disease and to control the periodontal status before any orthodontic appliance is placed.

Pain is a complex experience which accompagnies orthodontic treatment (50).

It is a subjective response showing large individual variations. The perception of orthodontic pain is part of the inflammatory reaction causing changes in blood flow following orthodontic force application. As a result of the inflammatory reaction, various biochemical mediators are released eliciting an hyperalgaesic response. The painful response during the first days of orthodontic treatment has been related to the release of neuropeptides which in turn evoke the release of pro-inflammatory cytokines, such as IL-6, IL-8 and TNF-α mainly by dental pulp cells and by other cell lines (63, 72). The levels of such mediators return to normal values after 14 days.

Orthodontic pain has a definite influence on compliance and daily activities of the patient. Many patients/parents consider initial lack of information about possible discomfort or pain, to be the major cause of poor compliance. Evaluation of pain is an important part of orthodontic treatment and the patients’ attitude towards orthodontics should be understood and discussed with the patient during the diagnostic phase. In our work described in chapter 3, a baseline interview was established in order to evaluate the patient’s previous experience of general and dental pain as well as the level of dental anxiety. Using the VAS, painful situations were proposed and the subjects had to place a mark on the line at a point that corresponds to the level of pain intensity. Regarding general pain, situations such as “cutting one’s finger”,

“being stung by nettles”, “vaccination” were proposed. Regarding dental pain,

situations such as “polishing”, “injection”, “drilling “ , “scaling “ were proposed. Finally, dental anxiety was assessed based on 4 questions regarding 4 hypothetical dental situations (“how you feel the day before the dental appointement”, “how you feel 5 min before” etc). This questionnary is a very simple and rapid method to evaluate our patient’s perception towards pain. Furthermore, we showed that several biochemical markers detected in GCF, such as PGE2, SP and IL-1β, were associated with pain intensity. The development of a chair-side biochemical test and a baseline interview

may help us to identify patients more “susceptible” to experience not just a discomfort but also high levels of pain during orthodontic treatment. This could further help us to manage pain and distress experienced by the patient. The administration of NSAIDs remains the preferred method for pain control (75). Low doses administered for one or two days in the initial stage of orthodontic treatment, or pre-operative analgesics administered at least one hour before every orthodontic procedure, will help the patient without affecting the tooth movement process.

Root resorption is a common sequela of orthodontic treatment (76-79).

According to its severity, root resortion is classified to cemental or surface resorption, to dentinal resorption and to circumferential root resroption. The last, is clinically the most severe type, it is irreversible and starts at or near the apex and progresses coronally, resulting in root shortening. The most commonly resorbed teeth are the maxillary incisors. In most of the cases, resorption defects are confined to the apical third of the root because the apical third is covered with cellular cementum, which depends on active cells and has more supporting vasculature (207). This makes it more vulnerable to trauma and cell-injury related reactions. Furtermore, there is a decrease in the hardness of the cementum from the cervical to apical regions, making apical areas prone to resorption (208). About 5% of adults and 2% of adolescents are likely to have at least one tooth with resorption of more than 5mm during active treatment. Until now, several factors have been identified as

predisposing factors for root resorption, such as age, gender, pre-existing root condition, type of tooth movement, amount and type of force as well as treatment duration (107-112).

An objective tool to identify teeth at risk of severe resorption is still missing.

Until now, OPT and periapical radiographs are the only tools in the diagnosis of orthodontically induced root resroption. However, a certain degree of resorption is required before being detectable on the radiograph, thus making impossible its detection at an early stage (124, 125). In chapter 7, we showed that digitized

periapical radiographs underestimated apical root resorption. Furthermore, in chapter 8, by using the CBCT as gold standard, we showed that OPT also underestimated orthodontically induced root resorption. We suggested that if signs of moderate root resorption are visible on OPT during the initial or middle phase of orthodontic

help make the decision on continuation and possible modification of orthodontic treatment. Furthermore, in cases of impacted canines, CBCT may be particularly useful in revealing the presence and degree of root resorptions on the adjacent teeth and when orthodontic treatment combined with surgery is required. Otherwise,

periapical radiographs should be obtained 6 months after the beginning of the

orthodontic treatment in order to early detect the occurence of apical root resorption.

Recently, the role of OPG and RANKL in osteoclast genesis and root

resorption- both physiologic and pathologic- procedure has been documented (187, 188). Furthermore, these molecules have been identified in the gingival crevicular fluid mainly in relation to periodontal disease (189, 190). The development of a screen test based on the detection of OPG and RANKL in gingival crevicular fluid, before and during orthodontic treatment, may help to identify patients at risk for root resorption. In our study based on experimental tooth movement, buccal tipping forces were exerted, thus we postulate that the buccal cervical and lingual apical region have undergone tissue compression. The buccal apical and lingual cervical areas were under tension, and the mid-root regions had undergone a mixture of both compression and tension. Based on the hypothesis that the levels of OPG and RANKlL may change in relation to the root resorption defects, the gingival crevicular fluid was collected in the compression areas during the whole experimental period.

Identifying biological markers related to root resorption, may help to the development of a screen test before any changes on root length become obvious in the

radiographs. Recently, research has been focused in identifying genes that control the cellular and ECM components associated with the events taking place during orthodontic tooth movement (115-118). A genetic test that will determine root resorption polymorphisms in patients prior to orthodontic treatment could contribute to the best clinical setting.

At present it is not possible for the clinician to predict patients at risk for severe root resorption during orthodontic treatment. Therefore, gingival crevicular fluid

analysis before or during orthodontic tooth movement, may be useful for the prediction of individual’s response to orthodontic treatment and the related side effects such as root resorption and pain. In particular, the detection of patients at risk and the early detection of root resorption before the radiographic observation are important areas in orthodontics that need to be addressed in order to improve the orthodontic treatment.


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