Refer at the point you are uncertain. You do not need to diagnose the periodontal problem, complete a full chart or decide which procedure is required. “Ortho-perio” and the proposed tooth movement are enough to start. We will investigate what is missing and coordinate with the orthodontist or GDP.

Why stabilisation comes first

Orthodontic treatment includes fixed braces and clear aligners. Both move teeth, so both require a healthy and stable periodontal foundation. Orthodontic appliances can also increase the challenge of plaque control, and tooth movement through an actively inflamed periodontium risks further attachment and bone loss. Current British Orthodontic Society guidance states that active periodontal disease must be treated and stabilised before orthodontic treatment begins.

Previous periodontitis is not, by itself, a reason to deny orthodontic treatment. Once periodontal endpoints have been reached, tooth movement may form part of a successful interdisciplinary plan, including in carefully managed Stage IV cases.

How deep is too deep?

There is no single pocket depth that can be read in isolation. Bleeding, suppuration, attachment levels, bone loss, plaque control, the response to treatment and the proposed movement all matter.

For orthodontic treatment in patients treated for Stage IV periodontitis, the EFP guideline recommends that periodontal-therapy endpoints are reached first: no 5 mm probing sites with bleeding on probing and no sites measuring 6 mm or deeper. If disease recurs during orthodontics, active movement should be paused at the affected teeth while periodontal stability is re-established.

A practical referral trigger

If there are pockets of 6 mm or more, 5 mm sites that bleed, suppuration, progressive bone loss, uncontrolled inflammation or uncertainty about stability, refer before active tooth movement. You do not need to complete the treatment first.

Keratinised mucosa and gingival phenotype

A narrow band of keratinised tissue or a thin gingival phenotype is not an automatic contraindication to orthodontics. The concern is site-specific: existing recession, inflammation, root prominence, dehiscence, tooth position and planned direction of movement can all change the risk.

Where tissue is vulnerable, periodontal treatment may include plaque-control support, removal of inflammation, root coverage or augmentation to increase tissue thickness or the band of keratinised mucosa. In selected cases, a soft-tissue graft is best completed before orthodontic movement. In others, treatment can be monitored and grafting considered later. The sequence should be agreed around the anatomy and orthodontic plan.

Surgical support for orthodontics

Olaria can provide the periodontal and surgical elements needed to help an orthodontic plan progress, including:

  • periodontal assessment and stabilisation before appliances or aligners
  • soft-tissue grafting and mucogingival surgery
  • regenerative treatment where indicated
  • surgical exposure of impacted canines for orthodontic traction
  • complex dental extractions required for the orthodontic plan
  • periodontal monitoring and supportive care during tooth movement

Send the orthodontic plan if you have it. If you do not, refer the concern and we can liaise with the orthodontist before deciding the surgical approach.

During orthodontic treatment

Patients with a history of periodontitis need tailored supportive periodontal care throughout orthodontics. Review should include plaque control, bleeding, probing depths, suppuration, recession and mobility, with radiographs where clinically justified.

The EFP recommends periodontal review ideally at each orthodontic appointment in treated Stage IV patients. The practical frequency for other patients depends on their history and risk. Good communication matters more than a rigid timetable.

What to send

Whatever you have. A proposed orthodontic plan, relevant radiographs, photographs, periodontal charting and the teeth of concern are useful. None is a condition of assessment. If the referral says only “ortho-perio”, canine exposure or complex extraction, we will contact the relevant clinician and establish what is needed.

What we return

We report the diagnosis, treatment completed, periodontal stability, any limits on movement and the maintenance plan. The patient can return after a single procedure, after full stabilisation or remain in shared periodontal care during orthodontics. As much or as little support as the referring team wants is fine.

Further reading: the EFP Stage IV periodontitis and orthodontics guidance and the British Orthodontic Society guidance on orthodontic treatment risks.