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Odovtos International Journal of Dental Sciences

On-line version ISSN 2215-3411Print version ISSN 1659-1046

Odovtos vol.23 n.3 San José Sep./Dec. 2021 

Clinical research

Oral health status after orthodontic treatment: a retrospective study

Estado de salud bucal después del tratamiento de ortodoncia: un estudio retrospectivo

DDS Gul  Yildiz Telatar¹

DDS Baris Can Telatar²

1Department of Restorative Dentistry, Recep Tayyip Erdogan University, Faculty of Dentistry, Rize, Turkey.

2Private Practice of Orthodontics, Rize Turkey.


Orthodontic appliances in the oral cavity may cause problems such as white spot lesions, dental plaque, periodontal disease and root resorption. The aim of this study was to investigate the association between orthodontic treatment and oral health parameters including visible dental plaque, gingival recession and white spot lesions (WSLs). A total of 170 patients (86 females, 84 males) were randomly selected to determine visible dental plaque, gingival recession and white spot lesions by using pre-treatment and post-treatment oral photographs. Except of previously extracted teeth, maxillary and mandibular incisors, canine, 1st and 2nd premolars and 1st molar were evaluated. There was a significant difference between the T0 (before treatment) and T1 (after treatment) groups in visible plaque (P< 0.001). The distribution of gingival recession frequencies according to Miller classification before treatment did not differ from the after treatment (P=082). A statistically significant increase in the severity of WSL was detected between the two time points (P< 0.001). Males have been shown to have higher WSL incidence after treatment. In conclusion, the present study showed that visible dental plaque and white spot lesions significant increase after orthodontic treatment. Considering the relationship between oral health and orthodontic treatment, clinicians and patients should know the risks and take precautions.

KEY WORDS Orthodontic treatment; Dental plaque; Gingival recession; White spot lesions


Los aparatos de ortodoncia en la cavidad oral puede causar problemas como lesiones de mancha blanca, placa dental, enfermedad periodontal y reabsorción radicular. El objetivo de este estudio fue investigar la asociación entre el tratamiento de ortodoncia y los parámetros de salud bucal, incluida la placa dental visible, la recesión gingival y las lesiones de mancha blanca (LMB). Un total de 170 pacientes (86 mujeres, 84 hombres) fueron seleccionados al azar para determinar la placa dental visible, la recesión gingival y las lesiones de manchas blancas mediante el uso de fotografías orales antes y después del tratamiento. Excepto los dientes extraídos previamente, se evaluaron incisivos maxilares y mandibulares, caninos, premolares y primeros molares. Hubo una diferencia significativa entre los grupos T0 (antes del tratamiento) y T1 (después del tratamiento) en la placa visible (P<0.001). La distribución de las frecuencias de recesión gingival según la clasificación de Miller antes del tratamiento no mostraron diferencias significativas con respecto al postratamiento (P=0.082). Se detectó un aumento estadísticamente significativo en la gravedad de LMB entre los dos puntos de tiempo (P<0.001). Se ha demostrado que los hombres tienen una mayor incidencia de LMB después del tratamiento. En conclusión, el presente estudio mostró que la placa dental visible y las lesiones de manchas blancas aumentaron significativamente durante el tratamiento de ortodoncia. Teniendo en cuenta la relación entre la salud bucal y el tratamiento de ortodoncia, los médicos y los pacientes deben conocer los riesgos y tomar precauciones.

PALABRAS CLAVE Tratamiento de ortodoncia; Placa dental; Recesión gingival; Lesiones de mancha blanca


Placement of fixed orthodontic appliances in the oral cavity may cause problems such as white spot lesions, dental plaque, periodontal disease and root resorpsions (1,2). Plaque bacteria in the oral cavity is the most important factor in the progression of periodontal disease and dental caries (3).

Oral hygiene maintenance becomes difficult due to the presence of brackets, belts, springs, coils and belt wires used during orthodontic treatment (4). Acidogenic bacteria metabolize carbohydrates and produce acid, which in turn leads to decrease of the plaque pH. When the pH of oral cavity is below 5.5, calcium and phosphate ions released from hydroxyapatite crystals in enamel. Thus, demineralization occurs in enamel and white spot lesions (WSL) are seen (5,6). Formation of the white spot lesions around orthodontic brackets can occur within 4 weeks after beginning of the treatment (7). The prevalence of white spots among orthodontic patients ranges from 2% to 96% (7,8).

The hypothesis is that orthodontic treatment negatively affect the oral hygiene maintenance, could increase dental plaque and demineralization. The objective of current retrospective study was to investigate the relationships between orthodontic treatment and oral health parameters including visible dental palaque, gingival recession and white spot lesions.


This study was approved by the Non-Interventional Clinical Research Ethics Committee of Recep Tayyip Erdogan University (protocol number: 2020/60). All procedures were performed in accordance with the Declaration of Helsinki and informed consent was obtained from all patients before being included in the study. The material of our study consisted of 170 individuals who were treated between 2017-2020 at the private orthodontic clinic in Rize, Turkey. Clinical oral photographs of patients were used before and after treatment for oral health evaluations. The exclusion criteria were the history of systemic or genetic diseases, regular medication use, cleft lip and palate, orthognathic surgery and fluorosis.

The oral health status, including visible plaque, gingival recession and white spot lesions was evaluated with the help of intraoral photographs by one calibrated examiner. Clinical oral photographs were captured using a Canon (Canon, Tokyo, Japan) digital camera 550D camera body with a 2.8/100 mm macro lens. The camera was equipped with Canon Macro Ring Lite MR-14EX II light flash.

Each intraoral photography including sagittal and frontal plane was analyzed on a computer screen in a room with dimmed ambient lighting. Then, the visible plaque, labial gingival recession and white spot lesions were recorded. Except of previously extracted teeth, maxillary and mandibular incisors, canine, 1st and 2nd premolars and 1st molar were evaluated. The visible plaque scoring on the photograhy was made according to the previously described study (9). According to Miller’s classification the gingival recession was scored (10).

Before (T0) and after treatment (T1), teeth were evaluated used a modified white spot lesion index (WSL-Index) by Gorelick et al (8). The visual slide evaluation of the individual teeth was based on a labial surface examination assessing the severity of WSL.

Intrarater reliability was assessed by comparing two measurements carried out by the examiner. The examiner first analyzed the parameters of 25 photographs, and then reanalyzed them in the same images 2 weeks later: A high level of agreement was found between two periods (coefficient alpha: 0.97).


The SPSS23.0 statistical software package was used for data processing. The Shapiro-Wilk test was used to test the likelihood that the distribution of data was normal.

The differences in three age groups across the mean age and mean treatment duration (month) were compared with Student’s t-tests. The chi-square (χ2) test was used for comparisons of gender and angle classification between the age groups.

The differences in before and after treatment across categories of gingival recession and white spot lesions were compared McNemar-Bowker test. Intergroup differences between treatment periods were investigated with paired t-test for visible plaque evaluation.


The patient demographic variables before treatment are presented in Table 1. The clinical photographs of 170 subjects (84 males and 86 females) with a mean age of 16.2 years were included in this study. Angle Class 3 frequency was significantly less frequent in the all age groups (p=0.027).

Distributions of visible plaque and gingival recession before and after orthodontic treatment groups are listed in Table 2. There was significant difference between the T0 and T1 groups in visible plaque (1.54±0.50; P < 0.001). Mean dental plaque was observed 0.5 (SD=0.2) in the pretreatment and and 2.1 (SD=0.4) in posttreatment groups, respectively. The distribution of gingival recession frequencies according to Miller classification before treatment did not differ from the after treatment (P=0.082).

The total number of white spot lesions at the two time points, T0 and T1, are presented in Table 3. Before treatment 3755 (93.7%) of the 4008 teeth did not exhibit WSL on the labial surfaces. The 10 teeth exhibited severe WSL at T0, after treatment severe lesions were found in 116 teeth. A statistically significant increase in the severity of WSL was detected between the two time points (P<.001).

It has been determined that the incidance of WSL after treatment tends to exhibit more WSL in males than in female patients (Figure 1). According to this, 248 teeth exhibited WSL in females and males had 342 WSL on their teeth after treatment.

Table 1 Demographic variables of the study. 

- Age ≤ 12 (n=57 12< Age >16 (n=58) Age ≥ 16 (n=55) Total
Age (mean±SD)ª 10.9±1.1 14.6±0.5 23.4±1.8 16.2±5.3
Gender (n, %)ᵇ - - - -
Female 28 (49.1) 30 (51.7) 28 (50.9) 86 (50.6)
Male 29 (50.9) 28 (48.3) 27 (49.1) 84 (49.4)
Treatment Duration (month) (mean±SD)ª 19±2.6 20±2.5 22±4.1 20.6±3.2
Angle Classification(n, %)ᵇ - - - -
Class 1 22 (38.6) 26 (44.8) 29 (52.7) 77 (45.2)
Class 2 20 (35.1) 22 (37.9) 24 (43.6) 66 (33.8)
Class 3 15 (26.3) 10 (17.2) 2 (3.6) 27 (21.0)

ªStudent’s t-test, ᵇ χ2 test.

Table 2 Distribution of visible plaque and gingival recession values in the patients. 

- Before Treatment (T0) After Treatment (T1) P-value
Visible plaque (mean±SD)ª 0.5±0.2 2.1±0.4 < 0.001
Gingival recession (by Miller index) (n, %)ᵇ - - -
Absent 3852 (96.1) 3847 (95.1) -
Class I 140 (3.5) 142 (4.2) .082
Class II 16 ( 0.4) 19 ( 0.7) -

ªPaired t-tests, ᵇMcNemar-Bowker test

Table 3 Number and percentage of buccal surfaces with WSL detected at T0 and T1 on photographs. 

- Before Treatment (T0) (n,%) After Treatment (T1) (n,%) P-valueª
No WSL 3755 (93.7) 3418 (85.3) <0.001
Slight WSL 241 (6.0) 420 (10.5) -
Severe WSL 10 (0.25) 116 (2.9) -
Cavitation WSL 2 (0.05) 54 (1.3) -

ªMcNemar-Bowker test

Figure 1 Distribution of the WSLs among the gender groups after treatment. 

Figure 2 Example of clinical oral photographs from one subject captured at before (T0) and after (T1) orthodontic treatment. The arrow used to show dental plaque, WSL is also seen in the circle. 


The purpose of current study was to investigate the relationships between orthodontic treatment and oral health parameters using intraoral photographs. In the literature, several researchers have used intraoral images to evaluate white spot lesions and periodontal status before, during, or after orthodontic treatment (8,11,12). In this study, standardized intraoral photographs were used to achieve the retrospective visual examinations. This method has also been referred in literature as a reliable method (9,13,14).

In present study, the visible plaque values increased statistically significant between the baseline and the end of treatment in all patients. This results are similar to the findings of the previous research, which presented that orthodontic appliances form a retention site for plaque (14). Similarly, Boke et al. have reported that the mean value of visible dental plaque showed significant increases during orthodontic treatment (11). Although some studies consistent that amount of dental plaque increases by fixed orthodontic treatment (15), some researchs have not observed increases (16,17). This difference might be attributed to the study duration times and educations given to patients (16).

The examination of gingival recessions in present study was carried out only on color images according to the Miller classification. This method demonstrated to be reliable, informative, and reproducible (18). According to our results, the distribution of gingival recession frequencies before treatment did not differ from the after treatment. Experimental evidence shows that orthodontic tooth movement does not actually cause gingival recession but can create an predisposing environment especially if the teeth are repositioned in a facial direction (19). It has been reported that orthodontic treatment is not main factor for gingival recession however it might has an indirect effect on gingival recession if teeth are repositioned in a labial direction. Recession during orthodontic treatment may not be progressive and the response may be more related to individual variation in the quality of the gingival tissues around specific dentoalveolar areas (20). Orthodontic treatment is not an important risk factor for the development of gingival recession. Although greater amounts of maxillary expansion during treatment increase the risks of posttreatment recession, the effects are minimal (21). Most studies assessing recession just after orthodontic treatment have been shown no relationship (22,23).

We found that 6.3% of the patients exhibited WSL already before treatment. This result lies within the range reported in previous study by Lavrov et al. (24). They speculated 15.5 % of pateints have WSL at the beginning of the treatment. In contrast, other studies reported much higher WSL prevalences before treatment due to the use of different WSL scoring systems and different WSL definitions (8,25,26). In present study, Gorelick index was used for WSL detection. The original or modification of this scoring system is commonly used for evaluation of WSL (13). Based on photographs examination this study showed showed that higher WSL prevalence associated with orthodontic treatments (8,27). Calculus formation and increased plaque accumulation during orthodontic treatment could be reason for new WSL development (28,29). It has also been reported that diffuculty of cleaning orthodontic appliances fixed at the critical sites leading to enamel decalcification and white spot lesion formation around orthodontic brackets (30).

In our study male patients have been shown to have higher WSL incidance after treatment. A previous study reported that male and female patients had WSL incidences of 46% and 29%, respectively after orthodontic treatment (31). Similarly, Boersma et al. found that 40% of the buccal surfaces in male patients had demineralization, compared with %22 in females (6). Julien et al. reported the percentage of male subjects who developed WSLs during treatment to be higher (%25) than the percentage of females (%22) (32). In contrast, Akin et al. suggested that gender was not a significant factor in WSL development (13). This gender difference may be due to the commonly reported better oral hygiene habits in female patients than in males (33).

There were limitations of this study. Oral hygiene habits of the patients could not be evaluated before the treatment. It has been reported that use of prophylactic fluoride supplements during orthodontic treatment might inhibit demineralization (13). The lack of present study was evaluation of the effectiveness of preventive treatments.


By using only standardized general photographic records, this study presented that the mean plaque values and white spot lesions exhibited significant increases during orthodontic treatment. Although gingival recessions were not associated with fixed appliance treatment. Considering the relationship between oral health and orthodontic treatment, clinicians and patients should know the risks and take precautions.


The authors declare no conflicts of interest.


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Received: November 24, 2020; Accepted: January 14, 2021; pub: March 02, 2021

Dr. Gul Yildiz Telatar -

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