Biomarkers in the gingival crevicular fluid used to detect root resorption in patients undergoing orthodontic treatment: A systematic review

Association Between Different Biomarkers and Initial Orthodontic Tooth Movement in Children and Adults: A Systematic Review and Meta-Analysis

The present systematic review aims to bridge the existing knowledge gap by evaluating the influence of various biomarkers on initial orthodontic tooth movement in children and adults. A systematic electronic search was conducted using relevant keywords across the databases PubMed, Google Scholar, and EBSCOhost to identify articles published in English until December 2023. The "Risk of Bias (ROB) in Non-randomized Studies of Interventions" (ROBINS-I) tool was used to assess the risk of bias, and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was applied to critically appraise the quality of evidence. A total of 10 studies were identified, all of which were non-randomised clinical trials that compared biomarker expression in patients belonging to the growing age group (children, juveniles, or adolescents) and adults, using gingival crevicular fluid (GCF) or saliva analysed by the ELISA method. Overall, younger patients consistently exhibited faster and more pronounced biological responses to orthodontic forces, with biomarker levels peaking within the first 72 hours of force application.

[Local administration of prostaglandins to accelerate the orthodontic movement. A literature review]

Objective

The search to optimize tooth movement and reduce treatment time is of great interest to the orthodontist, as it involves innovating new materials and procedures to achieve the treatment objectives in the short term. The administration of prostaglandins has been studied, and their effect on accelerating tooth movement when administered locally has been proven. The objective of this study was to evaluate the latest achievements concerning the effects of local administration of prostaglandins to accelerate tooth movement for orthodontic purposes.

Methodology

A search was conducted in four databases (PubMed, SciELO, Cochrane, Google Scholar) and three specialized journals (AJODO, Angle Orthodontics, Journal of Clinical Orthodontics) until August 2023. The methodological quality of the studies was analyzed using the PRISMA checklist.

Results

The study had 14 articles. Local administration of prostaglandins accelerates the speed of tooth movement and increases the number of osteoclasts. Evidence of root resorption has been reported concerning high doses of prostaglandins via the submucosal route and a reduction in root resorption by administering prostaglandins with calcium gluconate. Local administration of prostaglandins via the submucosal route produces mild to moderate pain, and inoculation with a local anesthetic is recommended. However, oral administration of the analogous compound Misoprostol does not produce pain or evidence of root resorption.

Conclusions

Sufficient scientific evidence has not been found to support the local administration of prostaglandins as a safe method to accelerate tooth movement in humans.

A newly developed kit for dental apical root resorption detection: efficacy and acceptability

OBJECTIVES

To determine the efficacy of a newly developed kit in dentine sialophosphoprotein (DSPP) detection and compare it with enzyme-linked immunosorbent assay (ELISA). User acceptance was also determined.

MATERIALS AND METHODS

This cross-sectional study consisted of 45 subjects who were divided into 3 groups based on the severity of root resorption using radiographs: normal (RO), mild (RM), and severe (RS). DSPP in GCF samples was analyzed using both methods. Questionnaires were distributed to 30 orthodontists to evaluate future user acceptance.

RESULTS

The sensitivity and specificity of the kit were 0.98 and 0.8 respectively. The DSPP concentrations measured using ELISA were the highest in the RS group (6.33 ± 0.85 ng/mL) followed by RM group (3.77 ± 0.36 ng/mL) and the RO group had the lowest concentration (2.23 ± 0.55 ng/mL). The new kit portrayed similar results as the ELISA, the optical density (OD) values were the highest in the RS group (0.62 ± 0.10) followed by RM group (0.33 ± 0.03) and the RO group (0.19 ± 0.06). The differences among all the groups were statistically significant (p < 0.05) for both methods. The Pearson correlation coefficient showed a statistically significant (p < 0.001) strong and positive correlation between DSPP concentrations and OD values.

CONCLUSIONS

The new kit was validated to detect the colour intensities of different severity of root resorptions. Most of the responses to the survey were positive towards the new kit for being a safer and simpler method to detect apical root resorption.

Biomarkers in External Apical Root Resorption: An Evidence-based Scoping Review in Biofluids

BACKGROUND

External apical root resorption (EARR), an unwanted sequela of orthodontic treatment, is difficult to diagnose radiographically. Hence, the current scoping review was planned to generate critical evidence related to biomarkers in oral fluids, i.e. gingival crevicular fluid (GCF), saliva, and blood, of patients showing root resorption, compared to no-resorption or physiologic resorption.

METHODS

A literature search was conducted in major databases along with a manual search of relevant articles in the library, and further search from references of the related articles in March 2021. The initial search was subjected to strict inclusion and exclusion criteria according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines.

RESULTS

Following PRISMA guidelines, 20 studies were included in the final review. The studies included human clinical trials and cross-sectional and prospective studies with/without control groups with no date/language restriction. Various biomarkers identified in EARR included dentinal proteins, enzymes, cytokines, and salivary proteins. Severe resorption had higher dentin sialoprotein (DSP) and resorption protein concentrations as well as lower granulocyte-macrophage colony-stimulating factor (GM-CSF) as compared with mild resorption. Increased DSP and dentin phosphophoryn (DPP) expression was found in physiologic resorption. Compared to controls, resorbed teeth showed a higher receptor activator of nuclear factor kappa B ligand/osteoprotegerin (RANKL/OPG) ratio. In contrast, levels of anti-resorptive mediators (IL-1RA, IL-4) was significantly decreased. Differences in force levels (150 g and 100 g) showed no difference in resorption, but a significant rise in biomarkers (aspartate transaminase [AST] and alkaline phosphatase [ALP]) for 150 g force. Moderate to severe resorption in young patients showed a rise in specific salivary proteins, requiring further validation. Limitations of the studies were heterogeneity in study design, biomarker collection, sample selection, and confounding inflammatory conditions.

CONCLUSIONS

Various biomarkers in biofluids indicate active resorption, while resorption severity was associated with DSP and GM-CSF in GCF, and a few salivary proteins. However, a robust study design in the future is mandated.

Influence of probiotics on the periodontium, the oral microbiota and the immune response during orthodontic treatment in adolescent and adult patients (ProMB Trial): study protocol for a prospective, double-blind, controlled, randomized clinical trial

BACKGROUND

Orthodontic treatment with fixed appliances is often necessary to correct malocclusions in adolescence or adulthood. However, oral hygiene is complicated by appliances, and prior studies indicate that they may trigger oral inflammation and dysbiosis of the oral microbiota, especially during the first 3 months after insertion, and, thus, may present a risk for inflammatory oral diseases. In recent periodontal therapeutic studies, probiotics have been applied to improve clinical parameters and reduce local inflammation. However, limited knowledge exists concerning the effects of probiotics in orthodontics. Therefore, the aim of our study is to evaluate the impact of probiotics during orthodontic treatment.

METHODS

This study is a monocentric, randomized, double blind, controlled clinical study to investigate the effectiveness of daily adjuvant use of Limosilactobacillus reuteri (Prodentis®-lozenges, DSM 17938, ATCC PTA 5289) versus control lozenges during the first three months of orthodontic treatment with fixed appliances. Following power analysis, a total of 34 adolescent patients (age 12-17) and 34 adult patients (18 years and older) undergoing orthodontic treatment at the University Hospital Erlangen will be assigned into 2 parallel groups using a randomization plan for each age group. The primary outcome measure is the change of the gingival index after 4 weeks. Secondary outcomes include the probing pocket depth, the modified plaque index, the composition of the oral microbiota, the local cytokine expression and-only for adults-serum cytokine levels and the frequencies of cells of the innate and adaptive immune system in peripheral blood.

DISCUSSION

Preventive strategies in everyday orthodontic practice include oral hygiene instructions and regular dental cleaning. Innovative methods, like adjuvant use of oral probiotics, are missing. The aim of this study is to analyse, whether probiotics can improve clinical parameters, reduce inflammation and prevent dysbiosis of the oral microbiota during orthodontic treatment. If successful, this study will provide the basis for a new strategy of prophylaxis of oral dysbiosis-related diseases during treatment with fixed appliances.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov in two parts under the number NCT04598633 (Adolescents, registration date 10/22/2020), and NCT04606186 (Adults, registration date 10/28/2020).

The effect of two different types of forces on possible root resorption in relation to dentin phosphoprotein levels: a single-blind, split-mouth, randomized controlled trial

Background

The purpose of this 2-arm-parallel split-mouth trial was to evaluate and compare the extent of possible root resorption using dentin phosphoprotein levels in gingival crevicular fluid between controlled continuous and intermittent orthodontic force groups.

Materials and methods

A sample of 16 maxillary first premolars from 8 patients requiring bilateral extractions of the upper first premolars as part of their orthodontic treatment were recruited. A buccally directed continuous force of 150 g, reactivated after 28 days, was applied to the upper first premolar on one side for 8 weeks. On the contralateral first premolar, a buccally directed intermittent force (21 days on, 7 days off) of the same magnitude was applied for the same period. Gingival crevicular fluid samples were collected at the beginning of the study, 1st, 3rd, 4th and 5th week, and at the end of the study to quantify and compare dentin phosphoprotein levels in both groups.

Results

Dentin phosphoprotein levels showed a higher concentration in the continuous force group than the intermittent force group in week 4 and 8 of sample collection; where the differences were statistically significant (95% CI 0.007–0.14; P < .04) and (95% CI 0.02–0.17; P < .04) respectively. No harm was observed.

Conclusions

Dentin phosphoprotein was found to be a useful early biomarker to detect and monitor root resorption, showing that the application of an intermittent orthodontic force caused less root resorption than a continuous force.

Trial registration

NCT04825665 ClinicalTrials.gov. Registered 1 April 2021—Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT04825665.

Bone turnover markers in gingival crevicular fluid and blood serum of patients with fixed orthodontic appliances

AIM

Bone remodelling can be followed through the bone turnover markers (BTMs). Aim of the present study was to record the fluctuation of an osteoclastic and an osteoblastic BTM [C-terminal telopeptide of type I collagen (CTX) and N-terminal pro-peptide of type I pro-collagen (PINP), respectively] in both the gingival crevicular fluid (GCF) and the serum of orthodontic patients before and after the initial application of orthodontic forces.

MATERIALS AND METHODS

Twenty-one Caucasian patients were prospectively evaluated. GCF and blood samples were collected in order to measure the selected biomarkers by ELISA at three time-points: exactly before, 5 days, and 14 days after bonding of the appliances. Standardized sample handling and patient preparation procedures were adopted in order to reduce pre-analytical variability.

RESULTS

GCF and serum CTX levels were found to be independent of age, although higher in the serum of female subjects. PINP levels were found higher in the serum of patients ≥25 years old, as well as in the GCF of males. A positive correlation between serum and GCF baseline PINP levels was observed.

LIMITATIONS

The effect of orthodontic treatment on bone remodelling might not be absolutely representative of the local bone microenvironment as the levels of the specific BTMs where measured within the GCF of the lower front teeth.

CONCLUSIONS

This is the first time PINP and CTX have been evaluated in the GCF and serum of orthodontic patients with fixed appliances. No statistically significant alterations of CTX and PINP levels in the GCF and the serum of patients were recorded over time during the initial stages of orthodontic treatment.

Orthodontic root resorption

External apical root resorption (EARR) is one of the most frequently reported iatrogenic side effects of orthodontic movement. Nevertheless, no robust and unequivocal scientific evidence is yet available in the literature regarding the clinical and biological factors that trigger EARR. The purpose of the present position paper is to provide clinicians, residents, and investigators a summary of our current understanding about root resorption caused by orthodontic tooth movement, based on up-to-date available scientific evidence. Morphological, structural, biomechanical, and biological differences account for predisposing the apical third to EARR compared to other root surfaces during orthodontic treatment. In addition, a relevant number of patient and treatment-related factors increase risk of EARR. The main patient-related factors are reviewed and discussed: genetic factors, tooth anatomy, demographic factors, malocclusion factors, previous endodontic treatment, medical history, short root anomaly. Similarly, the influence of treatment-related factors are analyzed with regard to the effect of: biomechanical factors, type of orthodontic appliance, adjunctive therapies to accelerate tooth movement, early treatment, maxillary expansion, teeth extractions, the duration of treatment and the amount of apical displacement. Clinical management of EARR from pre-treatment records to the monitoring strategy as well as recommendations for the post orthodontic-treatment period are presented as a guide for the clinician. Despite years of studies, we still do not fully understand EARR, but the future is promising. True three-dimensional imaging with higher resolution and low radiation, and predictive tools towards an earlier detection without radiographs, will mark future developments in the field of EARR in orthodontics.

Orthodontic treatment and root resorption: an overview of systematic reviews

BACKGROUND

Root resorption can be considered the most unfortunate complication of orthodontic treatment.

OBJECTIVE

To evaluate the available evidence regarding orthodontically induced inflammatory root resorption (OIIRR).

SEARCH METHODS

A comprehensive literature search was conducted for the systematic reviews investigating OIIRR published up to 24 May 2020. This was accomplished using electronic databases: MEDLINE via OVID, EMBASE, AMED (Allied and Complementary Medicine Database), PubMed, and Web of Science. Any ongoing systematic reviews were searched using Prospero and a grey literature search was undertaken using Google Scholar and OpenGrey (www.opengrey.eu/). No language restriction was applied.

SELECTION CRITERIA

Only studies investigating OIIRR were included.

DATA COLLECTION AND ANALYSIS

Screening, quality assessment [using the AMSTAR 2 tool (A Measurement Tool to Assess Systematic Reviews)], and data extraction were performed by two authors independently. Information was categorized and narratively synthesized for the key findings from moderate and high-quality reviews.

RESULTS

A total of 2033 potentially eligible studies were identified. After excluding the non-relevant studies, 28 systematic reviews were included. Of which, 20 systematic reviews (71.5%) were of moderate and high-quality level of evidence. The incidence and severity of OIIRR increase with the fixed appliance, especially with heavy force, intrusion, torqueing movements, increased treatment duration, and treatment with extractions or with long apical displacement (particularly for maxillary incisors). There was insufficient evidence regarding most other treatment- and patient-related factors on OIIRR. Following all precautionary measures, pausing treatment and regular monitoring benefits patients with OIIRR.

CONCLUSIONS AND IMPLICATIONS

There is a limited number of high-quality studies in terms of OIIRR. The influence of fixed appliance on root resorption was noted; however, the cause and effect relationship between OIIRR and orthodontic biomechanics has not been confirmed. Avoiding heavy, continuous forces and a greater amount of apical displacement over a long duration of treatment is recommended. Precautionary measures should be carefully considered when treating patients with a high risk of OIIRR.

REGISTRATION

CRD42020166629.

GWAS of Post-Orthodontic Aggressive External Apical Root Resorption Identified Multiple Putative Loci at X-Y Chromosomes

Personalized dental medicine requires from precise and customized genomic diagnostic. To conduct an association analysis over multiple putative loci and genes located at chromosomes 2, 4, 8, 12, 18, X, and Y, potentially implicated in an extreme type of external apical root resorption secondary to orthodontic forces (aEARR). A genome-wide association study of aEARR was conducted with 480 patients [ratio~1:3 case/control]. Genomic DNA was extracted and analyzed using the high-throughput Axiom platform with the GeneTitan^® MC Instrument. Up to 14,377 single nucleotide polymorphisms (SNPs) were selected at candidate regions and clinical/diagnostic data were recorded. A descriptive analysis of the data along with a backward conditional binary logistic regression was used to calculate odds ratios, with 95% confidence intervals [p < 0.05]. To select the best SNP candidates, a logistic regression model was fitted assuming a log-additive genetic model using R software [p < 0.0001]. In this sample the top lead genetic variants associated with aEARR were two novel putative genes located in the X chromosome, specifically, STAG 2 gene, rs151184635 and RP1-30E17.2 gene, rs55839915. These variants were found to be associated with an increased risk of aEARR, particularly restricted to men [OR: 6.09; 95%CI: 2.6–14.23 and OR: 6.86; 95%CI: 2.65–17.81, respectively]. Marginal associations were found at previously studied variants such as SSP1: rs11730582 [OR: 0.54; 95%CI: 0.34–0.86; p = 0.008], P2RX7: rs1718119 [OR: 0.6; 95%CI: 0.36–1.01; p = 0.047], and TNFRSF11A: rs8086340 [OR: 0.6; 95%CI: 0.38–0.95; p = 0.024]), found solely in females. Multiple putative genetic variants located at chromosomes X and Y are potentially implicated in an extreme phenotype of aEARR. A gender-linked association was noted.