Let them eat cake: the struggle between form and substance in orthodontic clinical investigation.

Events of the past decade or so argue that there is little support in the literature for much of the specialty's treatment portfolio. The resulting call for 'evidence-based' treatment (not to mention the obvious intellectual bankruptcy of much of the clinical literature) has prompted many to argue that the randomized clinical trial (RCT) represents the future of orthodontic clinical investigation. The RCT, after all, is medicine's gold standard; what more is there to say? A popular, but ultimately divisive, corollary of this mimicry is the smug tendency to discount all other sources of data. In the face of a need for information, this attitude is also a wasteful conceit: in the end, the RCT can be applied only to a very narrow spectrum of orthodontic questions. Randomization implies equal susceptibility. Any prospective participant would have to be informed of this equality as part of the informed consent process. Unfortunately, it would be nearly impossible to enroll fully-informed subjects into any study whose alternatives are of markedly different morbidity: extraction versus non-extraction or orthodontics versus surgery. Thus, when measured against the most vexing clinical questions, the orthodontic RCT is almost by definition an amusing diversion--expensive, but relatively trivial in scope. Like it or not, it seems reasonable to conclude that most of the specialty's comparative clinical data will have to be generated by way of non-randomized designs in which care is taken to minimize the various known sources of bias. There probably is no other way.     

Orthognathic surgery: an informed consent model

In this study, the authors propose an informed consent form for orthognathic surgery. A careful review of the international literature and clinical practice suggested the feasibility of dividing the informed consent form into two parts. In first part, the diagnostic procedures and the therapeutic and surgical times are described. The patient must sign it as soon he or she accepts the orthodontic/surgical therapy proposed. The second part describes the possible problems and difficulties of the procedure, and it must be read by the patient before starting the therapy. In the opinion of the authors, this informed consent form allows the patient to know the risks related to the orthodontic/surgical therapy, thus preserving the surgeons from the civil risk and penalties of omission.     

Medical emergencies in a dental office: inhalation and ingestion of orthodontic objects

BackgroundThe authors reviewed the literature regarding inhalation and ingestion of orthodontic appliances and suggest ways to manage and prevent these events.Types of Studies ReviewedThe authors conducted literature searches of free text and Medical Subject Headings terms by using PubMed and Embase databases and selected appropriate studies. They analyzed retrieved articles according to several parameters: inhalation or ingestion event, number of cases, patient's sex and age, type of orthodontic appliance, in-office event or out-of-office event, and medical treatment.ResultsThe authors found a total of 2,279 articles in their preliminary search. Eighteen reports of 24 cases from this search met all of the search criteria (that is, clinical studies, case reports or reviews limited to English, Hebrew or Arabic on any form of aspiration or inhalation of orthodontic appliances). Most cases (67 percent) involved ingested objects, and of those cases, the majority (57 percent) occurred in female patients. Most cases (85 percent) occurred outside the orthodontist's office. Seventeen patients (71 percent) had been treated with a fixed orthodontic appliance. In 60 percent of cases, the maxilla was involved. With one exception, no severe complications were reported (only seven patients were examined in a hospital emergency department), and patients were discharged uneventfully from the orthodontic office or emergency department.Clinical ImplicationsOrthodontists and team members should participate in medical emergency management courses that emphasize the use of guidelines in cases of inhalation or ingestion of orthodontic objects. Each orthodontist's office should develop written emergency protocols for out-of-office events and present them to patients and their parents at the start of treatment.     

Oral Hygiene Behavior of Croatian Adolescents during Fixed Orthodontic Treatment: A Cross-sectional Study

ObjectiveTo investigate the impact of fixed orthodontic treatment on adolescents'' oral hygiene behavior and to examine their food consuption during fixed orthodontic treatment, as well as their motivation to maintain oral hygiene.Materials and methodsThis research was carried out in a form of a survey questionnaire consisting of 23 questions. The sample comprised 170 adolescent patients aged from 11 to 19 who underwent the fixed orthodontic treatment at the Orthodontic Clinic of the Zagreb University Hospital Centre.ResultsThe orthodontic appliance did not interfere with the patients’ maintenance of oral hygiene, but it made the consumption of certain foods more difficult. Most adolescents brushed their teeth twice a day, using medium-soft brushes (35%). Regarding additional oral hygiene aids, 72.4% of the respondents used interdental brushes, more than 50% of the respondents used antiseptic mouthwashes for mouth rinsing, whereas only 31.2% of the tested population used dental floss (4.1% of which daily). The respondents were highly motivated to maintain oral hygiene by their orthodontists (96.5%), but only a small number of the respondents were informed about the importance of an adequate diet while undergoing a fixed orthodontic treatment.ConclusionOrthodontists should provide their patients with detailed instructions on hygiene maintenance and adequate diet during orthodontic treatment to minimize negative side effects of the fixed orthodontic treatment. Patients should be motivated upon each follow-up examination and encouraged to use as many oral hygiene aids in their daily routines as possible.     

Orthodontic Clinical Trials III: reporting of ethical issues associated with clinical trials published in three orthodontic journals between 1989 and 1998

AIMS: The aims of this study were to assess whether reports of orthodontic clinical trials complied with the requirements of the Declaration of Helsinki. DESIGN: A retrospective observational study. SETTING: The American Journal of Orthodontics and Dentofacial Orthopedics (AJODO), Journal of Orthodontics (formerly and up until 1999 known as the British Journal of Orthodontics, BJO) and European Journal of Orthodontics (EJO). DATA SOURCE: Clinical trials published between 1989 and 1998. METHODS: A hand search was performed to identify all clinical trials. Each trial report was assessed for inclusion of a statement that ethical approval and/or informed consent had been obtained. RESULTS: One-hundred-and-fifty-five papers were identified, of which 85 (54.8%) were reports of randomized controlled trials (RCTs) and 70 (45.2%) of controlled clinical trials (CCTs). 16.1% (25/155), of the trial reports stated that ethical approval had been obtained and a quarter (39/155, 25.1%) indicated that informed consent had been obtained. CONCLUSIONS: Most orthodontic clinical trial reports failed to state whether ethical approval and/or informed consent had been obtained. The reporting of the ethical issues associated with orthodontic clinical trials could be improved further not only by the instructions to authors in orthodontic journals stating the need for studies to comply with the Declaration of Helsinki, but also by Journal editors refusing to publish trials that do not comply.     

正畸疼痛的研究进展

疼痛是组织损伤或潜在组织损伤所引起的不愉快感觉和情感体验。正畸疼痛会对患者的依从性造成负面影响,也使得许多患者抵制正畸治疗。该文总结了现有的研究中关于正畸疼痛的研究进展,并针对在临床工作中医生和患者可能会产生的疑问寻找可靠的答案。     

Critical issues concerning root resorption: a contemporary review

Root resorption, an unwanted sequela of orthodontic treatment, has received much attention in the recent past. This is clearly evident from the enormous amount of literature published regarding this single iatrogenic issue. These research works should provide practitioners with great insight into the clinical, histologic, therapeutic, predictive, and genetic aspects as well as the molecular basis of the resorptive process. Yet the scientific community reading these reports is left with confounding questions requiring a proper organization of the published literature. This review is aimed at answering some critical issues concerning root resorption after orthodontic treatment. It also tries to update the theoretical information regarding the resorptive process, with an insight into recent human genetic and molecular-level research.     

Guest editorial: what do prospective randomized clinical trials tell us about the treatment of class II malocclusions? A personal viewpoint

The prospective randomized clinical trial (RCT) is seen by many to be the 'gold standard' for analysing treatment outcome and the only valid source of clinical data. In orthodontics, most RCTs have been designed to resolve the controversy surrounding the ability of functional appliances to significantly modify dentofacial growth. Given the variability in the timing, magnitude and duration of pubertal dentofacial growth, differing levels of motivation and patient compliance, the inherent inaccuracy of cephalometry and the questionable validity of the measurements themselves used to quantitate change, it is not surprising that the conclusions have not been as clear-cut as anticipated. Unlike a laboratory experiment, in which it is possible to limit the differences between experimental and control groups to the single factor being investigated, in a clinical trial an orthodontic appliance is just one of several variables affecting the outcome. Furthermore, RCTs are expensive and time-consuming; by the time the end-point of the study has been reached, the appliance may no longer be in widespread use, the fate of more than one recent well-publicized RCT.What RCTs have shown is that functional appliances such as the Herbst and twin block, based on the principle of 'jumping the bite', are more effective at modifying dentofacial growth and reducing overjets than headgear and more passive appliances such as the Andresen activator and its variants. However, if one asks whether RCTs have achieved their objective, or provided knowledge not previously available from retrospective studies or animal experimentation, then the answer would have to be no; it is also hard to justify the cost. What is particularly interesting is that knowledge based on years of clinical experience has been disregarded and then announced as if it was something completely new.     

Timing terapeutico e concetto di “urgenza” ortodontica. Linee guida e revisione della letteratura

Objectives

The objective of the study is to define the optimal timing of “urgent” orthodontic treatment of malocclusions.

Materials and methods

We conducted a systematic review of the literature that contained quantitative and qualitative data on the timing of orthodontic treatment of various types of malocclusions. Our analysis centered on articles indexed in the Medline database that had been published from 1970 through November 2010, including review articles, meta-analyses, and randomized and controlled clinical trials (RCT and CCT).

Results and conclusions

Our analysis of the literature indicates that there are “urgent” orthodontic problems that require prompt treatment, even if the permanent teeth have not erupted. These cases include crossbites, skeletal class III malocclusion, certain behavioral anomalies, the presence of obstacles to eruption or supernumerary teeth, and early tooth shedding. In these cases, early treatment often prevents the later development of severe, frequently skeletal malocclusions.     

A Survey of Patients' Preferences for the Treatment of Teeth with Apical Periodontitis

Introduction

This research aimed to investigate the preference of patients in Toronto, Canada for management of a tooth affected by painful apical periodontitis when considering its retention via root canal treatment (RCT) and its extraction followed by no replacement, replacement with an implant-supported crown, fixed, or removable partial prostheses.

Methods

Data were collected through a mail-out survey of the University of Toronto Faculty of Dentistry patients, which was complemented by a convenience sample of patients in 10 community practices in Toronto (n = 1000, response rate = 43%). Participants were asked to select their general preference for anterior and posterior teeth with apical periodontitis between saving the tooth or extraction and their specific preference for tooth retention via RCT or extraction. By using bivariate and logistic regression analyses, we applied the Gelberg-Andersen Behavioral Model for Vulnerable Populations to the preference questions to understand the influential factors (P ≤ .05).

Results

Participants' specific preference for tooth retention via RCT was slightly but significantly lower than their general preference (anterior tooth, 93.7% versus 97.2%; posterior tooth, 83.8% versus 89.6%; P < .005). Higher annual income, previous RCT, functional dentition, good/excellent self-rated oral health, and regular dental visits were associated with higher preferences for tooth retention in response to different questions.

Conclusions

The high preference for retaining a tooth in general was moderated by the specific consideration of RCT to retain the tooth. When RCT and extraction are viable options, patients should be advised about the treatment options in an impartial manner and encouraged to communicate their preferences.     

Value-addition of lateral cephalometric radiographs in orthodontic diagnosis and treatment planning

ObjectiveTo investigate the value-addition of obtaining lateral cephalometric radiographs during the treatment planning phase of orthodontic treatment.Materials and MethodsThe records of 100 orthodontic patients were presented to seven scorers during two phases that were 6 weeks apart. In the first phase, scorers completed a seven-question survey with questions regarding treatment planning. They were given various diagnostic records that did not include a lateral cephalometric radiograph. Six weeks later, the same scorers completed the same survey for the same patient cases with the same diagnostic records that additionally included a lateral cephalometric radiograph. Correlation coefficients were used to calculate intrarater agreement and inter-rater agreement within the study.ResultsCohen''s kappa values showed moderate to almost perfect agreement for the majority of survey questions. Intrarater agreement ranged between 0.430 and 1. Cronbach''s alpha reliability statistics showed good interrater agreement for all questions in the survey. Agreement ranged from 0.710 to 0.913 across the survey questions. Diagnosing Angle classification of occlusion had the highest level of agreement and differentiating between skeletal and dental malocclusion had the lowest level of agreement.ConclusionsThe lateral cephalometric radiograph is not a necessary diagnostic tool for most cases in orthodontic diagnosis and treatment planning. Weighing the usefulness of a lateral cephalometric on a case-by-case basis should be recommended to align with the principle of ALARA (as low as reasonably achievable), especially in a primarily pediatric population.     

Evidence summary: which dental liners under amalgam restorations are more effective in reducing postoperative sensitivity?

Since August 2009, members of the Primary Care Dentistry Research Forum (www.dentistryresearch.org) have taken part in an online vote to identify questions in day-to-day practice that they felt most needed to be answered with conclusive research. The question that receives the most votes each month forms the subject of a critical appraisal of the relevant literature. Each month a new round of voting takes place to decide which further questions will be reviewed. Dental practitioners and dental care professionals are encouraged to take part in the voting and submit their own questions to be included in the vote by joining the website. The paper below details a summary of the findings of the ninth critical appraisal. In order to address the question raised by dentistry research forum, first a search was conducted for systematic reviews on the topic. There was one systematic review retrieved comparing bonded amalgam restorations versus non-bonded amalgam restorations. However, there was no other systematic review identified assessing the effectiveness of dental liners under amalgam restorations in general. Therefore, a search was conducted for any randomised controlled trial (RCT) comparing use of a lining under amalgam restorations versus no lining or RCTs comparing differing lining materials under amalgam against each other. There were eight relevant RCTs identified. Due to the low quality, small sample sizes or lack of adequate reporting of the outcome data, the evidence is inadequate to claim or refute a difference in postoperative sensitivity between different dental liners. Further well-conducted RCTs are needed to answer this question. These RCTs would be preferably included and synthesised in a systematic review.     

Dental trauma: part 2. Managing poor prognosis anterior teeth – treatment options for the subsequent space in a growing patient

Abstract

Part 1 concentrated on implications of dental trauma especially prior to and during orthodontic treatment. This paper examines the literature supporting various treatment options for poor prognosis anterior teeth and subsequent space generated when these teeth are lost. The role of an interdisciplinary team in managing this clinical situation is essential to obtain optimal results and an orthodontist is an essential member. Although some treatment options are not provided by orthodontists it is important that they have some knowledge of these and the latest research that support their use. Other techniques lie very much within the orthodontic remit.

Treatment options can be split into maintaining the failing tooth or extraction and restoration of the edentulous gap. This paper reviews various treatment options including periodontal regeneration, surgical repositioning and distraction osteogenesis, composite build up to incisal levels and decoronation when maintaining a failing tooth. When extraction and restoration of edentulous gap is required the following treatment modalities are discussed: extraction technique to retain bone quantity, orthodontic space closure and opening (site development), autotransplantation, partial denture, resin bonded bridge and implants. All these options should be considered and available to an interdisciplinary team to ensure optimal care of children with anterior teeth of poor prognosis.     

Quality of life and economic burdens of malocclusion in U.S. patients enrolled in Medicaid

BackgroundPatients enrolled in Medicaid have limited access to orthodontic services in the United States. No studies are available, to the authors' knowledge, regarding the clinical and psychosocial burdens of malocclusion on these patients from an economic perspective.MethodsThe authors conducted a systematic review of the relevant economic literature. They identified issues from the perspectives of the various stakeholders (dentists, patients and parents, Medicaid programs) and developed a conceptual model for studying decision making focused on the strategy of providing early interceptive and preventive treatment rather than, or in addition to, comprehensive care in the patient's permanent dentition.ResultsMedicaid coverage and reimbursement amounts vary nationwide, and decision making associated with obtaining care can be complex. The perspectives of all relevant stakeholders deserve assessment. A conceptual framework of the cost-effectiveness of interceptive orthodontic treatment compared with comprehensive treatment illustrates the issues to be considered when evaluating these strategies.ConclusionsPolicymakers and the dental community should identify creative solutions to addressing low-income families' limited access to orthodontic services and compare them from various perspectives with regard to their relative cost-effectiveness.Clinical ImplicationsDentists should be aware of the multiple problems faced by low-income families in obtaining orthodontic services and the impact of stakeholder issues on access to care; they also should be proactive in helping low-income patients obtain needed orthodontic services.     

Orthodontic pain: from causes to management--a review

Orthodontic pain, the most cited negative effect arising from orthodontic force application, is a major concern for parents, patients, and clinicians. Studies have reported this reaction to be a major deterrent to orthodontic treatment and an important reason for discontinuing treatment. Surprisingly this area, which requires attention in clinical practice as well as in research, is ignored as evidenced by the scarcity of publications on the topic in comparison with other areas of orthodontic research. This review attempts to organize the existing published literature regarding pain, which appears as part of orthodontic mechanotherapy and to address questions that might arise in a clinical setting from the viewpoint of clinicians and patients/parents. It also provides an overview of current management strategies employed for alleviating orthodontic pain.     

The Feasibility and Validity of Orthodontic Screening of Children in Their Tenth Year

Abstract

The study set out to investigate the problems of the implementation of the Court Report's suggestion that every child in its tenth year should be screened for orthodontic treatment by ‘a dentist with special training in orthodontics’ using Grainger's Treatment Priority Index (TPI). The study was divided into two parts. The standardization exercises used 31 orthodontic models of children in their tenth year. The problem of examiner variability, using a Community Dental Officer instead of an orthodontist and of bias that the TPI might have were examined. The main study involved the examination of 362 children in ten separate schools in Oxfordshire and investigated the problem of orthodontic screening at annual school inspections. The findings showed that the TPI may be able to provide a method for screening children in their tenth year if the weights of the clinical entities which are reducing the level of validity of the TPI are identified. The problem of scoring tooth displacements consistently would have to be taken into consideration when training personnel to use the TPI.     

Diagnosis and Management of Juvenile Rheumatoid Arthritis with TMJ Involvement

This article presents a literature review of juvenile rheumatoid arthritis along with a clinical case. The clinical picture of such patients is given, including the common medical and dental findings, their management and the prevalence of temporomandibular joint involvement. The authors found TMJ involvement in such patients to be frequent and the micrognathic degree to be directly related to the age of juvenile rheumatoid arthritis onset. For the case presented here, tomographs were taken to demonstrate anatomically the cause of the patient's limited TMJ function. The patient's chief complaint was about her unesthetic dental appearance. The treatment rendered to the patient was restorative in nature. The article also discusses orthodontic and surgical interventions within the scope of the overall treatment.     

Pilot study comparing parents' and third-grade schoolchildren's attitudes toward braces and perceived need for braces

Abstract An instrument developed for third-grade schoolchildren and their parents was pilot-tested for its ability to measure orthodontic attitudes and perception of the child's need for braces. Seventy-eight children and 54 parents were surveyed. Forty-six percent of the children wanted braces while 61% believed that they needed braces. Correlation between desire for braces and perceived need was 0.47, suggesting that desire and perceived need were only moderately correlated in children. Sixty-three percent of the parents believed that their child needed braces. Despite such proportions of children and parents perceiving a need for treatment, three-fourths of the children and two-thirds of the parents were satisfied with the appearance of the child's teeth. Attitude subscales, derived from the attitude survey, and clinical orthodontic parameters were used to model children's and parents' perceived need for braces in the child. No clinical parameter was a significant correlate in either children's or parents' model of perceived need. Neither race nor gender contributed significantly to either model. The subscales Concern for Appearance and Social Aspects of Braces were the strongest covariates of children's perceived need for braces. Concern for Appearance was the most important correlate in the parents' model. These data suggest that parents' perceived need for orthodontic treatment for their third-grade children is determined primarily by a concern for appearance rather than clinical status. In third-graders, perceived aesthetics and social aspects apparently have more influence than clinical status in creating a perception of need for braces.     

What is the most effective adhesive for attaching orthodontic bands?

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline and Embase were used and a search of the internet also undertaken. There was no restriction with regard to publication status or language of publication. STUDY SELECTION: Randomised controlled trials (RCT) and controlled clinical trials (CCT), including split-mouth studies, of adhesives used to attach orthodontic bands to molar teeth were selected. DATA EXTRACTION AND SYNTHESIS: All review authors were involved in study selection, validity assessment and data extraction without blinding to the authors, adhesives used or results obtained. All disagreements were resolved by discussion. RESULTS: Five RCT and three CCT were identified as meeting the review's inclusion criteria. All the included trials were of split-mouth design. Four trials compared chemically cured zinc phosphate and chemically cured glass ionomer; three trials compared chemically cured glass ionomer cement with light-cured compomer; one trial compared chemically cured glass ionomer with a chemically cured glass phosphonate. Data analysis was often inappropriate within the studies that did meet the inclusion criteria. CONCLUSIONS: There is insufficient evidence to determine the most effective adhesive for attaching orthodontic bands to molar teeth in patients with full-arch fixed orthodontic appliances.