Professional consensus on orthodontic risks: What orthodontists should tell their patients

Patients' perceptions matter: Risk communication and psychosocial factors in orthodontics

INTRODUCTION

Effective risk communication is essential for achieving patient-centered oral health care, but the limited understanding of patients' subjective perceptions of orthodontic-related risks hinders this process. This study aimed to investigate adults' awareness, concerns, and risk-avoidance behaviors about long-term orthodontic risks, exploring their relationship with psychosocial factors.

METHODS

We included 498 adult patients (mean age, 27.3 ± 6.8 years; women, 75.5%) during their initial visits to the orthodontic department at a hospital in Chengdu, China. Participants' understanding of orthodontic risks was gauged before and after exposure to the Oral Health Education Comics (OHEC), a specifically designed digital tool. Concurrently, we used logistic regression models to investigate the associations between patients' depression, anxiety, self-esteem, perfectionism, and dentofacial esthetics with risk perceptions.

RESULTS

Approximately 79.5% of participants initially reported low awareness of orthodontic risks, with most knowledge from online sources. Notably, the percentage of participants with high awareness increased to 64.8% after OHEC. The negative facial soft-tissue change was most concerning for participants: 53.4% showed high concerns, and 28.1% showed high avoidance. Furthermore, linear regression indicated positive associations between depression (β = 0.42 [95% confidence interval {CI}, 0.07-0.77]) and anxiety (β = 0.76 [95% CI, 0.35-1.18]) with orthodontic risk concerns, whereas risk avoidance was positively associated with depression (β = 0.62 [95% CI, 0.27-0.97]), anxiety (β = 1.09 [95% CI, 0.68-1.50]), and perfectionism (β = 0.24 [95% CI, 0.02-0.46]).

CONCLUSIONS

Findings emphasize the imperative of streamlined risk communication in orthodontics. By incorporating comprehensible tools such as OHEC and integrating psychosocial evaluations, more refined patient-practitioner communication and psychosomatic-based dental care can be achieved.

Clear aligner therapy informed consent forms: A quality and readability evaluation

OBJECTIVE

The aim of the present study was to evaluate the quality and readability of content contained within clear aligner therapy (CAT) informed consent forms.

METHODS

CAT informed consent forms were identified via an online search. The presence of details related to CAT-related processes, risks, benefits and alternatives in each form was recorded. A 4-point Likert type scale was used to determine the quality of content (QOC). The readability of content was evaluated with the Simple Measure of Gobbledegook (SMOG) and Flesch Reading Ease Score (FRES).

RESULTS

A total of 42 forms satisfied selection criteria. Nineteen (45.2%) were authored by companies who provided aligners to patients via clinicians. The QOC regarding CAT-related treatment processes [median 2.0; IQR 0, 2] and benefits [median 2.0; IQR 1, 2] was adequate. The QOC scores regarding treatment alternatives, consequences of no treatment and relapse were poor. There was no difference (P=0.59) in the median (IQR) QOC of the informed consent forms provided by direct-to-consumer (DTC) aligner providers [10 (8.25, 16.25)] and non-DTC aligner providers [12 (10, 14)]. The median (IQR) SMOG score was 12.1 (10.9, 12.7) and FRES was 39.0 (36.0, 44.25).

CONCLUSIONS

The QOC of the evaluated forms was incomplete and poor. The content was difficult to read and failed to reach recommended readability standards. Consent is unlikely to be valid if it is based solely on the content of the forms. Clinicians need to be aware of the limitations of informed consent forms for CAT particularly in relation to alternatives, prognosis, risks, and the need for long-term maintenance of results.

Evaluation of the use of a clinical practice guideline for external apical root resorption among orthodontists

BACKGROUND

External apical root resorption (EARR) is a frequently observed adverse event in patients undergoing fixed appliance therapy. Assessing the patients' risk during treatment is important, as certain factors are assumed to be associated with an increased likelihood of occurrence. However, their predictive value remains limited, making evidence-based clinical decision-making challenging for orthodontists. To address this issue, the Dutch Association of Orthodontists (NvVO) developed a clinical practice guideline (CPG) for EARR in accordance with the AGREE II instrument (Appraisal of Guidelines for Research and Evaluation II) in 2018. The aim of this study is to get insight into the actual utilization and the practical implementation of the guideline among orthodontists. The hypothesis to be tested was that after its introduction, clinical practice for EARR has changed towards the recommendations in the CPG.

OBJECTIVE

To investigate the use of the 2018 clinical practice guidelines for EARR among orthodontists 3 years after its introduction.

METHODS

A questionnaire using a 7-point Likert scale was developed concerning four domains of EARR described in the guideline. The questionnaire was piloted, finalised, and then distributed digitally among Dutch orthodontists. REDCap was used for data collection, starting with an invitation email in June 2021, followed by two reminders. Effect was tested by the Mann-Whitney U test, and the influence of demographic variables was analysed.

RESULTS

Questionnaires were sent out to all 275 and completed by 133 (response rate 48%); N = 59 females and N = 73 males were included; 81% had their training in the Netherlands, 89% had ≥ 6 years of work experience, and 89% worked in private orthodontic practice. One hundred thirty orthodontists (98.5%) reported changes in clinical practice. The biggest positive change in clinical behaviour regarding EARR occurred if EARR was diagnosed during treatment. Sex, clinical experience, country of specialist training, and working environment of the respondents did not affect clinical practices regarding EARR.

CONCLUSIONS

This questionnaire demonstrated that, 3 years after introduction of the guideline, orthodontists improved their self-reported clinical practices to a more standardised management of root resorption. None of the demographic predictors had a significant effect on the results.

Resin infiltration for white spot lesions: An in vitro experimental trial

OBJECTIVE

To evaluate the aesthetic outcome by varying the duration allowed for infiltrant penetration when treating white spot lesions with resin infiltration.

DESIGN

An in vitro, experimental randomised study.

METHODS

Artificially created white spot lesions (WSLs) were induced on 100 extracted anterior teeth (T1). Teeth were divided into enamel and dentine groups depending on the extent of the lesion and then randomly assigned into different treatment protocol groups: penetration times of 3, 6 and 9 min. Resin infiltration treatment was applied according to the treatment protocol assigned (T2). Samples were thermocycled for 10,000 cycles (1 clinical year) (T3). The samples from the 3-min enamel and dentine groups were then randomly assigned into either a repeat treatment or no additional treatment group (T4). Samples were then thermocycled for an additional 10,000 cycles (T5). Spectrophotometric analysis was measured colour change (ΔE) for all groups.

RESULTS

Mean ΔE values equal to or greater than the critical value (3.7) indicate a detectable clinical difference in colour of the treated WSL when compared to before WSL formation. Mean ΔE values, for the enamel groups, were slightly above or significantly below the critical value, and for the dentine groups, were significantly above the critical value. Mean ΔE values within the enamel and dentine groups both demonstrated a downward trend with increasing time allowed for resin infiltrant penetration (P < 0.05). No significant mean ΔE difference (P = 0.53) was found between groups that received a single or repeat treatment. After the first thermocycling event, no significant difference in colour change was observed in all groups except for the deep dentine lesion treated for 3 min. There was a significant difference in colour change for all groups except the enamel group that received a single treatment following thermocycling after a single or repeat treatment.

CONCLUSION

Increasing the resin infiltrant penetration time to at least 9 min is advised as the most optimised treatment protocol. Resin infiltration treatment should be done only once to treat a particular white spot lesion as subsequent treatment for the same lesion results in marginal colour improvement. The colour improvement of WSLs resulting from the resin infiltration treatment can be expected to last for at least 1 year. Resin infiltration treatment of shallow lesions with a single and optimised infiltration technique can be expected to last an additional year.

Contemporary Twin Block appliance wear protocols: A survey of UK orthodontists

OBJECTIVE

This study was undertaken to determine contemporary trends in the use of the Twin Block appliance among UK orthodontists, including the wear time currently prescribed. In addition, the study explored if there had been any change in wear time prescribed, considering recent research evidence proposing part-time wear.

DESIGN

Cross-sectional, online survey.

PARTICIPANTS

Members of the British Orthodontic Society (BOS).

METHODS

The questionnaire was emailed to all BOS members in November 2021 and hosted on the QualtricsXM platform. The questionnaire was piloted for content validity and tested for reliability.

RESULTS

A response rate of 19% was attained. Nearly all (n = 244, 99%) participants used the Twin Block, and 90% (n = 218) prescribed full-time wear including/excluding eating. Although the majority (n = 168, 69%) had not made changes to their wear time prescriptions, nearly one-third (n = 75, 31%) had. Those who reported a change in their prescriptions currently prescribe less wear time than before, and commonly quoted 'research evidence' as the reason. A wide range in success rates (41%-100%) was reported, with patient compliance as the main reason for treatment discontinuation.

CONCLUSION

The Twin Block is a popular functional appliance among orthodontists in the UK, originally designed by Clark to be worn full time to maximise functional forces applied to the dentition. However, this wear regime may place considerable strain on patient compliance. Most participants prescribed full-time Twin Block wear excluding eating. Approximately one-third of orthodontists made changes to their wear time prescriptions during their practising career, and currently instruct less wear time than before.

Orthodontic Risk Perspectives among Orthodontists during Treatment: A Descriptive Pilot Study in Greece and Slovakia

This study explores orthodontists' perspectives on risks associated with orthodontic treatment, as described by Greek and Slovak orthodontists. Informed by the foundational importance of effective communication of risk perspectives in health sciences, particularly in facilitating valid consent and shared decision-making, this research addresses gaps identified in the literature concerning the consistent communication of potential treatment risks based on demographic and cultural characteristics. This study identifies 15 potential critical risks during orthodontic treatment. These risks include root resorption; temporary undesired changes to the occlusion; sleep difficulties; not achieving an ideal result; development of black triangles between teeth; taking additional X-rays; speech difficulties; using a protective splint during sports; duration of treatment; number of visits; transmission of infectious diseases; and swallowing orthodontic appliances. A questionnaire, distributed electronically to orthodontists in Greece (N1 = 570) and Slovakia (N2 = 210) from September 2022 to December 2022, aimed to assess risk communication practices, taking into consideration socio-demographic factors, such as country, gender, age, and academic-degree-related variations. A total of 168 valid questionnaires (91 from Slovakia and 77 from Greece) were obtained, indicating significant disparities in the risks emphasized and preferred forms of consent. The Greek orthodontists focused more on the risks involved, such as relapse, root resorption, temporal occlusal changes, and failure of desired movement, while the Slovak practitioners tended to be more interested in sleeping difficulties, temporal occlusal changes, and not achieving an ideal result. They also obtained written or digital consent from patients or their parents/guardians more frequently than the Greek team. Male orthodontists discussed specific risks more frequently, including relapse and extractions, whereas females preferred written or digital consent. PhD-trained orthodontists prioritized certain risks, indicating the need for tailored approaches. This study underscores the dynamic nature of risk assessment in orthodontic practice, emphasizing its ethical and strategic dimensions. The findings advocate for tailored risk communication strategies that recognize individual, contextual, and cultural factors, and the need for an orthodontic informed consent protocol for a tailored communication approach for patients to elevate the standard of care in European orthodontics. The reliance on digital tools reflects contemporary trends in enhancing patient understanding, thereby supporting ongoing innovation in orthodontic practices.

Compliance of orthodontic practice websites with ethical, legal and regulatory advertising obligations

BACKGROUND AND OBJECTIVES

The aim of the study was to investigate the degree to which the websites of orthodontists in Australia comply with the regulatory frameworks regarding healthcare advertising.

METHOD

The websites of orthodontist practices in Australia were assessed against Section 133 of the National Law and the Australian Health Practitioner Regulation Agency (AHPRA)'s guidelines pertaining to the advertising of regulated health services. Website content was assessed in relation to 5 domains regarding the provision of false and misleading information, the use of offers and inducement without clear terms and conditions, the use of patient testimonials, the creation of unrealistic expectation of benefit and the encouragement of the indiscriminate and unnecessary use of health services.

RESULTS

The websites of 166 orthodontist practices and 304 orthodontists satisfying inclusion/exclusion criteria were evaluated. Intra-rater agreement was high, ranging from 0.91 to 0.97. Most websites (80.7%) contravened the Law in one or more domains. The mean number of non-compliant domains per website was 2.2 (95% CI: 1.96 to 2.46). Information that was likely to create unrealistic expectations of orthodontic treatment (74.1%) was the domain most frequently breached with clinical information that only discussed the benefits of treatments contained in 64.5% of websites. Named commercial products were contained within 88.6% of the websites with links to commercial product manufacturers provided by 36.7%.

CONCLUSIONS

Compliance of orthodontist practices in Australia with ethical, legal and regulatory advertising requirements is lacking. Orthodontists must exercise greater diligence in ensuring that the ethical requirements of preserving patient safety are not jeopardised by the advertising of their healthcare services.

Quality assessment of online information on orthodontic Web sites in the United States

INTRODUCTION

The objective of this study was to assess the quality of online information on orthodontic treatment provided by orthodontic Web sites in the United States and investigate their claims.

METHODS

Three hundred and one American orthodontic Web sites were identified after an advanced Google search. Data collection included: the location of the clinic, treatment options offered, quality-of-information assessment using the DISCERN tool, and finally, claims when promoting 1 treatment option against another, as well as the presence of information on relapse risk and retention needs.

RESULTS

All Web sites belonged to private clinics, with more than half (60.5%) in a single location. Invisalign (Align Technology, Santa Clara, Calif) was the most commonly promoted treatment option (94%), followed by the full fixed appliance (FFA) (92%). The mean DISCERN total score was poor (36.78 out of 80.00), whereas the mean reliability (questions 1-8) and quality-of-information (questions 9-15) scores were 17.06 out of 40.00 and 16.85 out of 35.00, respectively. Almost one-third (28%) of the Web sites compared aligners to FFA, whereas 25% claimed that aligners are less painful than FFA, faster than FFA (14%), or give better results than FFA (1%). Almost half of the Web sites (47%) failed to display information on relapse risk and retention needs after orthodontic treatment (41%). The Web sites that displayed such info had higher DISCERN total scores (P <0.001).

CONCLUSIONS

Invisalign seems to be the treatment modality most commonly mentioned online. According to DISCERN, U.S. orthodontic Web sites display poor or fair quality information. On many Web sites, aligner treatment was compared with FFA, with some stating that aligners cause less pain than FFA or are more efficient/faster than FFA. Moreover, almost half of the American orthodontic Web sites failed to display information on the relapse risk or retention need. Display of such information can be an indicator of better-quality Web sites. There is ample room for improvement in the online information American orthodontists provide to potential patients.

INFLUENCE OF BAD HABITS ON THE DEVELOPMENT OF ACQUIRED DEFORMATIONS IN THE MAXILLOFACIAL AREA

OBJECTIVE

The aim: Identifying the relationship between the presence of oral habit and acquired maxillomandibular anomalies, influence of oral habits on the skeleton and muscular system formation in children.

PATIENTS AND METHODS

Materials and methods: We conducted clinical, radiological methods of examination of 60 patients aged 9-12 with acquired maxillomandibular anomalies, 15 persons aged 9-12 years without maxillomandibular anomalies and acquired deformities (norm group) and 15 persons aged 9-12 years with hereditary syndromes, which are combined with bone deformities in the maxillofacial area (comparison group).

RESULTS

Results: Clinical examination showed that oral habits were manifested in 98.3% of patients. The results of clinical and radiological examination, analysis of cephalometric parameters and data on the thickness of the masticatory muscles on symmetrical areas of the face confirm the relationship between chronic oral habits and formation of acquired maxillomandibular anomalies; confirm the presence of acquired rather than congenital deformity of the facial skeleton, which is associated with changes in the thickness of the masticatory muscles on the part of the deformation та compensatory muscle hypertrophy on the opposite side.

CONCLUSION

Conclusions: The oral habit should be considered as one of the triggers in the development of acquired deformities of the maxillofacial area.