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BASED ORTHODONTICS
Dr. Sonal SahasrabudhePost Graduate
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Contents
• Introduction• Definition• History• Need for evidence based orthodontics• Evidence based practice & EBDM• Clinical scenarios• Experience Vs Evidence• Conclusion• References
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INTRODUCTION
• The field of orthodontics has the distinction of being the first recognized speciality in dentistry.
• With this, we also inherited the responsibility to lead in the acquisition , evaluation and dissemination of scientific knowledge.
• But the mechanisms by which we acquire, assess and transfer the knowledge have changed considerably over the period of time.
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SO WHAT ELSE CHANGED ?
The PatientInformed, aware, curious ,skepticalDefinitely more demandingDoctor-Patient RelationshipA partnership
The needTreatment on demand, timed,Needs to fit in with lifestyleA result
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DEFINITIONS
• EVIDENCE• Generally, an article published in a scientific journal- reporting
results of a clinical trial- is considered as evidence.
• EVIDENCE BASED DENTISTRY• ADA: “ an approach to oral health care that requires the
judicious integration of systematic assessments of clinically relevant scientific evidence , relating to patient’s oral and medical condition and history, with the dentist’s clinical expertise and patient’s treatment needs and preferences.
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HISTORY OF EBD• Origin in the middle of 19th century in Paris, when young
graduates started challenging the validity of clinical decisions based solely upon personal experience.
• McMaster University in Canada in 1985 , introduced some concepts in its curriculum.
• American College of Physicians followed.• Establishment of Center for Evidence- based Medicine in Oxford,
UK in 1995.• The litigious nature of society further fueled the need for
practicing evidence based health care
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Dr. Angle’s contributions
Teaching
Invention of new
appliances
Conducting clinical
researchAge of Edward Angle• His Views• His teaching
Age of Education• Teaching in
dental schools
Age of Science• World war II• Scientific
innovations
Age of Evidence• Public- better
informed• Questioning of
established ideas
Evolution of knowledge acquisition
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Need for clinical evidence…?
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Need for evidence based orthodontics???
“Simply because we, as health care professionals, owe it to our patients, to provide the currently best care available”
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• Its primary purpose is to improve patient care. • Intended to close the gap between what is known and what is
practiced; to improve patient care based on informed decision-making.
• EBP consists of three components or legs of support:
Doctor’s education and experiencePatient’s preferences and valuesBest available evidence
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Health care is all about decision making
Right time
Right intervention
Right patient
Right method
Best results
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How does one arrive at a clinical decision that is valid, current and applicable to
one’s patient?
Evidence-Based Care
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How EB is developed?
• Evidence-based clinical recommendations are developed through critical evaluation of the collective body of evidence on a particular topic to provide practical applications of scientific information that can assist orthodontists in clinical decision-making.
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TYPES OF STUDIES
STUDIES
EXPERIMENTAL OBSERVATIONAL
RCT COHORT CASE
CONTROLCASE
REPORT
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Types of Reviews
Reviews
Systematic
Narrative Syntheses Meta-analyses
Pooled Estimates
Narrative
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HIERARCHY OF EVIDENCE
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1. SYSTEMATIC REVIEWS & META ANALYSES• Systematic reviews are a synopsis of the existing evidence on a
specific topic.• It is a process of systematically locating, appraising and
synthesizing evidence from scientific studies in order to obtain a reliable overview.
• Provides means to keep up with numerous articles published annually in every field.
• Concentrates on a very specific and narrow, clinically relevant question.
• Team of experts• Inclusion and exclusion criteria is used• Bias less likely to happen
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• Guidelines for the conduct of a systematic review- COCHRANE COLLABORATION.
• Provision of software to perform statistical analyses of pooled data.
• Systematic reviews are often considered qualitative assessments, whereas meta-analyses are quantitative evaluations.
• Meta-analyses may be inappropriate where heterogeneity in clinical, methodological, or statistical approach argues against combining studies.
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What is meta-analysis?
• It is a review that uses quantitative methods to combine the statistical measures from two or more studies and generates a weighted average of the effect of an intervention, degree of association between a risk factor and a disease, or accuracy of a diagnostic test.
• Distinguishing feature of meta-analyses- Use of statistical analysis because the other steps involved in meta-analyses are identical to those of systematic reviews.
• Most often, the results of meta-analyses - presented using forest plots.
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Forest Plot
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Types of Meta-analysisRandom effect analysis
Fixed analysis
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STEPS IN PERFORMING SYSTEMATIC REVIEW
• FIRST STEP : framing an important and well defined question that is relevant to patient care.
• Framing a question in a proper format and identifies four crucial “ PICO” elements. These elements are:
1. Population or patient type 2. Intervention3. Comparison 4. Outcome
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• SECOND STEP: determining inclusion and exclusion to select the eligible studies.
• THIRD STEP: design a search strategy.• Employed to search available studies include both electronic
databases such as MEDLINE, EMBASE, Web of science and Cochrane, databases and manual searches.
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• FOURTH STEP: involves application of the selection criteria identified in step Two to the potential studies retrieved from both electronic and manual search strategies determined in step Three.
• This action will result in selection of the eligible studies for the review and appraising these studies.
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• FIFTH STEP: Performing a statistical summary of the abstracted data, or Meta- analysis.
• Data from different study designs are summarized with the purpose of the following six tasks:
1. Deciding whether to combine the data or defining what to combine
2. Evaluating the statistically heterogeneity of the data3. Estimating a common effect4. Exploring and explaining heterogeneity5. Assessing the potential for bias6. Presenting the results in the form of a table
• FINAL STEP: Interpret the evidence to answer the research question
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Drawbacks of SRs and MAs
• SRs• Selection bias• Publication bias• Heterogeneity
• MAs• Ability of researchers to
combine studies that differ in study populations, experimental designs, and quality controls
• Possibility of publication or selection bias when conducting such studies
• Oversimplifying the results of a research area
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2. RANDOMISED CONTROL TRIALS
• An experimental study on patients with a particular disease or disease –free subjects in which the individuals are randomly assigned to either an experimental intervention or a control group to determine the ability of an agent or a procedure to diminish symptoms, to decrease risk of death from disease during follow up period.
• Provide strongest evidence of causation.
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Drawbacks
• Raise ethical concerns in control groups
• Costly and time consuming to implement
• Because of the strict eligibility criteria and loss to follow-up, RCT sample size requirements are difficult to attain and maintain
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3. COHORT STUDIES• An observational study that follows an exposed cohort
compared to an unexposed cohort to determine the incidence of given outcome.
• Well designed cohort study provides strong support for causation
• Require large sample size• Take a long follow-up time to generate useful data of the
studies - result in misclassification in outcome status• Expensive to conduct• Are sensitive to attrition
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4. CASE CONTROL STUDIES• An observational epidemiological study of persons with the disease
(or another outcome variable) of interest and a suitable control group of persons without the disease (comparison group, reference group) – Done retrospectively
• Quick, relatively inexpensive• Appropriate in studying rare diseases• Assessment of multiple risk factors for a particular disease within
the same study
Potential recall bias. Confounding of exposure variable. Matching control to cases is challenge.
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5. CASE REPORT AND CASE SERIES
• Document unusual occurrences of outcomes
• First clues of a new diseases or adverse effects of exposure
• Case series are an extension of case reports
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How to search for the evidence?
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Sources
Personal experienceTextbooksOwn professional educationClinical guidelinesColleagues ,other professionalsPatient Personal intuitionTrial and errorSupplier ,infomercial literatureJournal articlesOnline referenceUnpublished evidenceOverviews
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Sources
• The National Library of Medicine’s searchable database of more than 12 million indexed citations from more than 4600 medical, dental, health, and scientific journals
1. PubMed
• An international non-profit organization that develops evidence-based systematic reviews on health care interventions
2. Cochrane Collaboration
• A resource for evidence-based dentistry that is periodically updated and accessible to dentists and the public.
3. ADA Center of Evidence-Based
Dentistry
• An example is the evidence-based website that the AAO Library maintains at its member website.4. Websites
• The group conducts systematic reviews of randomized controlled trials of health-care interventions and diagnostic tests, which it publishes in The Cochrane Library.
• The group was formed to organize medical research information in a systematic way to facilitate the choices that health professionals, patients, policy makers and others face in health interventions according to the principles of evidence-based medicine.
The Cochrane Oral Health Group
• Part of The Cochrane Collaboration • Established in the USA in 1994• Comprises an international network of researchers involved in
producing and disseminating systematic reviews of controlled RCTs in the field of oral health.
• Publishes summaries of the best quality research available to help people (patients, carers, clinicians, researchers and funders) make better informed decisions about oral healthcare choices.
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Evidence Based Decision Making (EDBM)
EBDM is the formalized process and structure for learning these skills with the purpose of closing the gap between what is known and what is practiced in order to improve patient care based on informed decision-making.
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Evidence based decision making
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The Need for EBDM
• Forces driving the need to improve the quality of care include:
Variations in practice
Slow translation and assimilation of the scientific evidence
into practice.
Managing the information overload, and changing
educational competencies that require students to
have the skills for lifelong learning
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• Convert information needs/problems into clinical questions so that they can be answered • Conduct a computerized search with maximum efficiency for
finding the best external evidence with which to answer the question • Critically appraise the evidence for its validity and usefulness
(Clinical applicability).• Apply the results of the appraisal, or evidence, In Clinical practice.• Evaluate the process and your performance.
EBDM PROCESS
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Clinical scenarios in Orthodontics
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Face mask protraction therapy in early skeletal Class III
AJO DO 2005 128; 299-309
• Does RME enhance the efficiency of maxillary protraction with face mask in developing Class III malocclusion?
• Results: Face mask therapy effective in early Class III MO
• The need for palatal expansion in the absence of a transverse discrepancy or a skeletal/ dental cross bite is not supported.
• Correction due to combined skeletal and dental change.
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Critical appraisal EBD 2006:7,16-17.
• First prospective RCT of the subject
• Inclusion of control group to quantify growth before recruiting participants.
• Results are conclusive.
• The skeletal change following protraction is significant, but has no correlation with expansion.
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Skeletal and dental changes with fixed slow maxillary expansion treatment. Systematic review.
JADA Feb 2005 • Eight studies were selected, each lacked a control group, and
four also did not have a measurement error treatment.
• A control group is necessary to factor out normal growth changes in the dental arch and cranio facial structure.
• No strong conclusion could be made on dental and skeletal changes after SME.
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Meta analysis of immediate changes with RME treatment JADA Jan 2006
• Results: Of the 31 selected abstracts, 12 were rejected because they failed to report immediate changes after the activation phase of RME and instead reported changes only after the retention phase.
• The greatest changes were in the maxillary transverse plane in which the width gained was caused more by dental expansion than true skeletal expansion.
• Few vertical and antero-posterior changes were statistically significant, and none was clinically significant.
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A systematic review concerning early orthodontic treatment of unilateral posterior cross bite
Angle Orthod 2003;73:588-596
• The aim of this study was to assess the orthodontic treatment effects on unilateral posterior cross bite in primary and early mixed dentition by systematically reviewing the literature.
• Two RCT’s of early treatment of cross bite have been found and these two studies support grinding as treatment in the primary dentition.
• There is no scientific evidence to show which of the treatment modalities, grinding, quad helix, expansion plates or RME is most effective
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Orthodontics and Temporo-mandibular Disorders – A meta-analysis
AJO DO 2002;121:438-446
• Orthodontists are blamed for causing TMD. Epidemiologic studies show that TMD symptoms are most prevalent among patients between 15-25 years of age. Orthodontists may encounter patients who complain about TMD during or after treatment.
• Does traditional orthodontic treatment change the prevalence of TMD?
• No study indicated that traditional appliance increased the prevalence of TMD, except for mild or transient signs
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The effect of topical fluorides on decalcification in patients with fixed orthodontic appliances: A systematic review
AJO DO 2005; 128: 601-606
• Decalcification is a significant problem during fixed orthodontic treatment. Topical fluorides can reduce or eliminate the problem, but the relative effectiveness of different or combinations of topical fluoride preparations is unknown.
• Results: The use of topical fluorides in addition to fluoride toothpaste reduced the incidence of decalcification in populations with both fluoridated and non fluoridated water supplies. Different preparations and formats appear to decrease decalcification but there was no evidence that any one method was superior.
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Incremental versus maximum bite advancement during Twin block therapy: A randomized controlled clinical trial.
AJO-DO 2004;126:583-8
•Experimental patients had 2mm initial bite advancement and subsequent 2mm advancements at 6 weekly intervals with a Twin block appliance incorporating advancement screws.•The aim of this study was to evaluate the effectiveness of incremental and maximum bite advancement during treatment of class II div 1 malocclusion with the Twin-block appliance in the permanent dentition.•The use of incremental advancement of the twin block did not confer any advantage in terms of process and outcome of the treatment.
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Outcomes in a 2-phase RCT of early class II treatment AJO DO 2004;125:657-667
This study was a RCT designed to examine the 2 major strategies used to treat class II malocclusion: 1 phase Vs 2 phase
Results: there was no differences in the findings between the ‘intent to treat’(ITT) sample,who had completed phase 1,and an ‘efficacy analyzable’(EA)sample(n=137),which comprised only patients who completed phase 2.During phase 2 of the trial,the advantage created during phase 1 treatment in the 2 early treatment group was lost,and by the end of fixed appliance treatment,there was no significant difference between any of the 3 groups for all anteroposterior and vertical skeletal and dental measures.
The experienced-basedview
The evidence-based view
1. Only clinical experience, and years of it, is relevant to the practitioner.2. Denies the usefulness of
science3. Research journals are biased
against the experienced-base view.
4. There are no good clinical studies or clinical researchers.
1. Science and scientific methods are relevant to practitioner.2. Benefits and usefulness of science have been demonstrated3. Referred research journals are not biased.4. Clinical research is adequately performed and published.
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Experience based Vs. Evidence based
• A common criticism is that the findings of clinical trials are not relevant to patients in private practice, because the operators in trials are working to such tight protocols that their treatment bears no resemblance to the real world.
• Treatment decisions based on clinical experience and beliefs are extremely difficult to change.
• Clinical experience suggests that some conditions are best treated for biological, social, or practical reasons
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Experience based Vs. Evidence based
• For the experience- based orthodontist, what is accepted as the knowledge of the field is apparently based on some combination of:
1. empiricism 2. authority 3. rationalism and 4. tenacity
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Drawbacks of experience based approach
Definitive answer is not available with the provider but working plan is provided based on knowledge of pathophysiological processes / memory of similar clinical problems.
Fear of unconventional problems which do not follow the textbook pattern & failure to update with current trends & treatment modalities.
A difference in opinions of clinical experts, will not provide adequate scientific information for consistent & reliable clinical decision making
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CONCLUSION
• The main challenge for the orthodontist is the necessity of integrating the gathered evidence into clinical practice.
• Without the incorporation of current best evidence, clinical practice may be based more on anecdote or tradition, and risks becoming rapidly out of date which surely is not in the best interest of our patients.
• Nevertheless, the AAO states that an evidence-based approach does not set a standard of care, and that the treatment for each patient should be based on a combination of the doctor’s clinical expertise, the patient’s needs and preferences, and the evidence.
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REFERENCES• Rinchuse D J, Rinchuse D J. Evidence- Based Clinical Orhtodontics. Edited by
Miles P G. Quintessence Publishing co, Inc.• Making the case for evidence- based orthodontics- Greg J Huang. Am J Orthod
Dentofac Orthod 2004; 125: 405-6.• Putting the evidence first- David L Turpin. Am J Orthod Dentofac Orthod 2005;
128:415.• Adeyemo WL. Is there evidence against evidence based dentistry? Am J Orthod
Dentofacial Orthop 2007;132:3.• Isaacson RJ. Evidence based Orthodontics. Angle Orthod. 2002; 72(6): iv.• Rubin RM. On Evidence-based Orthodontics. Angle Orthod. 2006; 76(5): 911-
12.• Cunha-Cruz J. Practicing evidence-based Orthodontics: How to critically
appraise a randomized controlled trial. Dental Press J Orthod. 2015 Mar-Apr;20(2):12-5.
• Angelieri, F. Evidence-based Orthodontics: Has it something to do with your patient? Dental Press J Orthod. 2013 Sept-Oct;18(5):11-3.
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REFERENCES• Gianelly A. Evidence-Based therapy: An Orthodontic dilemma Am J Orthod
Dentofac Orthod,Volume 129,Number 5.• Phil Banks, Jean Wright & Kevin O’Brein . Incremental versus maximum bite
advancement during twin block therapy : A randomized controlled clinical trial. AJODO 2004; 126: 583-8.
• J.F.Camilla Tulloch, William R. Proffit & Ceib Phillips. Outcomes in a 2-phase randomized clinical trail of early Class II treatment. AJODO 2004; 125: 657-67.
• Mahmoud Torabinejad & Khaled Babjri. Essential elements of evidenced- based endodontics: Steps involved in conducting clinical research. JOE 2005; 35: 563-8.
• Barbara L Chadwick, Jayne Roy, Jeremy Knox & Elizabeth T Treasure. The effect of topical fluorides on decalcification in patients with fixed orthodontic appliances: A systematic review. AJODO 2005; 128: 601-6.
• Myung- Rip Kim, Thomas M Graber & Marlos A Viana. Orthodontics & temporomandibular disorder: A meta- analysis. AJODO 2002; 121: 438-46.
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REFERENCES• Petren S, Bondemark L, Soderfeldt B. A Systematic Review Concerning
Early Orthodontic Treatment Of Unilateral Posterior Crossbite. Angle Orthodontist, Volume 73, Number 5,2003.
• Kalha A S. Face mask protraction therapy in early skeletal class III malocclusion. EBD 2006:7.1.
• Manuel Lagravere,Paul Major,Carlos Flores-mir. Skeletal and dental changes with fixed slow maxillary expansion treatment. JADA,Volume-136,February 2005.
• Manuel Lagravere,Giseon Heo,Paul Major,Carlos Flores Mir. Meta-analysis of immediate changes with rapid maxillary expansion treatment. JADA,Vol.137,January 2006.
• Graber, Vanarsdall, Vig. Orthodontics: Current Principles and Techniques. 5e. Elsevier. Searching for evidence in orthodontics. Chapter 21. 2027-2042.
60Thank You
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