Clinical Practice Guidelines

This blog is based on the Clinical Practice Guidelines published by Sondeijker and the team from the Netherlands in 2020. To put Clinical Practice Guidelines into context, they are a set of recommendations (not mandatory) aimed at improving the quality of care for patients through a series of statements developed for a specific topic which has a large degree of uncertainty. We have written the blog in a first person format as they are questions we should be asking ourselves when root resorption occurs in light of the above clinical practice guidelines.

There are two main clinically relevant areas this blog will focus on:

1. The management of root resorption when it happens due to orthodontic treatment.
2. The follow-up protocol after orthodontic treatment

It is worth mentioning clinically relevant root resorption was defined at loss of 2mm or more of root length

1. How do I manage root resorption when it occurs?

When root resorption starts during orthodontic treatment, there is a risk that it will continue. So, the practitioner should know when to continue, pause or completely stop treatment.

Continue, pause or stop completely?

• It is important to inform the patient about the findings and have a detailed discussion with the patient (The Duty of Candour)
• The practitioner should re-evaluate treatment goals and determine the subsequent treatment strategy together with the patient. Treatment may be continued modified or stopped.
• Continue Vs stop: The risk of continuing treatment is of a near certainty of further root resorption, and should be balanced against the limited orthodontic objectives of ending the treatment, below are a list of factors to consider:
  1. Current occlusion, stable / unstable
  2. Patient’s esthetic perception
  3. Amount of tooth movements required to complete treatment

If I continue orthodontic treatment, what do I need to consider?

• Pause treatment for at least 3 months, this immediately stops the progression of root resorption and can enable some root surface repair, as resorption lacunae heal with the removal of orthodontic forces (Lavendar, 1994). Then continue treatment with light forces and longer intervals, take a new radiograph to evaluate root resorption after 6 months of restarting treatment.
• If root resorption is localized, management is to exclude the affected tooth from the active appliance.
• If root resorption is generalized, it is recommended to end treatment to prevent further harm.

If I stop orthodontic treatment, what do I need to consider?

• First thing to note is with stopping orthodontic treatment it has been shown that the root resorption process stops immediately (Copeland & Green, 1986).
• Retention of the achieved orthodontic outcome, with consideration of avoiding orthodontic forces through unbalanced occlusal forces, see below for details.

Flow diagram of the Clinical Practice Guidelines – adapted from Sondeijker

2. The follow-up protocol and aftercare for patients who developed root resorption

Once treatment is complete or stopped, retention and follow up are the next stage. It is important to share the likely long-term outcome of root resorption (mostly favourable) with the patient and their dentist.

Follow-up protocol

• Retainers: A retainer should be constructed as passive as possible to prevent non-axial forces on the teeth. It is important this is reassessed at each follow up important to avoid the retainer becoming active and imparting unwanted orthodontic forces.
• Assess the amount of root resorption, and inform the patient that they might feel some mobility in the affected teeth and that it may increase overtime if the remaining root length is less than 10mm Becker 2005.
• Long-term prognosis of moderate – severe root resorption is favorable, with teeth retained for up to 25 years.
• Avoid any further loss in the alveolar bone level, it is important to inform the dentist about any root resorption more than 2mm and advise bone loss can affect the long term prognosis of the teeth.
• The dentist should focus on the periodontal status of affected teeth and maintain optimal oral hygiene with the patient to prevent periodontal disease development.

Contributions

• Contents by Kerolos AlHakeem 
• Contents by James Andrews 
• Edited and contents by Farooq Ahmed

We hope you have enjoyed this blog, This blog started with a conversation between Kerolos AlHakeem, Farooq Ahmed and James Andrews, to follow more conversations, clinical tips and commentaries on orthodontics please check us out on Instagram:

Kerolos AlHakeem’s Instagram page @dr_al_hakeem

James Andrews’ Instagram page @dr.jamesandrews

Farooq Ahmed’s Instagram page @farooqahmed_orthodontist