Severe periodontal disease presents unique challenges for orthodontic treatment, prompting critical ethical considerations regarding the balance between potential benefits and risks of harm. This narrative review synthesizes peer-reviewed literature to explore the ethical boundaries of initiating or continuing orthodontic therapy in patients with advanced periodontal involvement. Key themes include the pathophysiological interplay between orthodontic forces and compromised periodontal tissues, the risks of exacerbated bone loss and tooth mobility, the benefits of improved esthetics and function, and the application of ethical principles such as beneficence, non-maleficence, autonomy, and justice. Emphasis is placed on the pivotal role of informed consent, multidisciplinary collaboration, and patient-centered decision-making to ensure treatment aligns with ethical standards. The review concludes that orthodontic treatment can be ethically justified in select cases with stabilized periodontal conditions, rigorous maintenance, and clear communication of uncertainties, but must be avoided when risks predominate, to uphold the do-no-harm imperative.
