An RCT on clinical effectiveness and cost analysis of correction of unilateral posterior crossbite with functional shift in specialist and general dentistry

OBJECTIVES

To evaluate the costs of quad-helix (QH) and removable expansion plate (EP) treatments performed either in specialist or general dentistry for the correction of unilateral posterior crossbite with functional shift in the mixed dentition.

TRIAL DESIGN

Four-arm parallel group multicentre randomized controlled trial.

MATERIALS AND METHODS

One hundred and ten patients with unilateral posterior crossbite with functional shift were recruited. The patients were randomized by an independent person not involved in the trial. The randomization used blocks of 20 and into the following four groups: QH treatments in specialist orthodontic clinics (QHS), QH treatments in general dentistry (QHG), EP treatments in specialist orthodontic clinics (EPS), and EP treatments in general dentistry (EPG). Blinding was accomplished of the outcome assessor and data analyst. A cost analysis was performed with reference to intention-to-treat (ITT), regarding direct costs, indirect costs, and societal costs (the sum of direct and indirect costs) for calculations of successful treatments alone and for retreatments when required. To determine which alternative has the lower cost, a cost-minimization analysis was undertaken, based on that the outcome of the treatment alternatives were broadly equivalent, so the difference between them reduces to a comparison of costs.

RESULTS

In the QHS group, 28 of 28 patients were successfully corrected compared to 23 of 27 in the QHG group. Treatment with expansion plate was less successful: 18 of 27 patients in the EPS group and 18 of 28 in the EPG group. QH treatment performed in specialist orthodontic clinics had significantly lower costs than QH or EP treatment accomplished in general dentistry as well as EP treatments in specialist orthodontic clinics.

LIMITATIONS

Costs depend on local factors and should not be directly extrapolated to other locations.

CONCLUSION

Treatment of unilateral posterior crossbite in the mixed dentition is recommended to be performed by a specialist orthodontist using the QH appliance.

TRIAL REGISTRATION

The trial was not registered.

Three-dimensional evaluation of forced unilateral posterior crossbite correction in the mixed dentition: a randomized controlled trial

Objectives

The objectives of this study were to assess the three-dimensional (3D) treatment changes (palatal surface area and volume) of forced unilateral posterior crossbite correction using either quad-helix or removable expansion plate appliances in the mixed dentition, and to compare the treatment changes with the three-dimensional changes occurring in age-matched untreated unilateral posterior crossbite patients as well as in subjects with normal occlusion and with no or mild orthodontic treatment need.

Trial design

Six-arm parallel group multicentre randomized controlled trial.

Materials and methods

One-hundred and thirty-five patients with unilateral posterior crossbite with functional shift were recruited. The patients were randomized by an independent person not involved in the trial. The randomization used blocks of 25, and the patients were randomized into the following five groups: quad-helix treatments in specialist orthodontic clinics (QHS), quad-helix treatments in general dentistry (QHG), removable expansion plate treatments in specialist orthodontic clinics (EPS), removable expansion plate treatments in general dentistry (EPG), and untreated crossbite (UC). Twenty-five patients with normal occlusion who served as normal controls were also included in the trial. Blinding of the outcome assessor and data analyst was accomplished. Data on all children were evaluated on an intention-to-treat basis, regarding 3D palatal surface area, palatal projection area, and palatal shell volume; two-dimensional linear measurements were registered at the same time.

Results

After treatment, the surface and projection area and shell volume increased in the four treatment groups (QHS, QHG, EPS, and EPG). QHS increased significantly more than EPG for the surface and projection area. The QHS and EPS had significantly higher mean difference for shell volume.

Limitations

The trial considers a short-term evaluation.

Conclusion

After treatment, there were no significant differences between the four treatment groups and the normal group, which implies that the surface and projection area together with the shell volume for the four treatment groups and the normal group were equivalent.

Trial registration

The trial was registered with https://www.researchweb.org/is/sverige, registration number: 220751.

Do fixed orthodontic appliances cause halitosis? A systematic review

Objective

To examine: (I) the current evidence of the impact of fixed orthodontic appliances on the development of halitosis in patients undergoing orthodontic treatment, and (II) the influence of different orthodontic bracket systems on halitosis.

Material and methods

Three electronic databases (PubMed, Scopus, and Cochrane Library) were searched prior to March 15, 2018. The review was systematically conducted and reported according to the Cochrane Handbook and the PRISMA statement. Only Randomised Clinical Trials (RCTs) were considered. Selected full-text papers were independently assessed by four investigators and any disagreements were resolved by consensus. The Cochrane Handbook was used to grade the risk of bias and the quality of evidence was rated according to GRADE.

Results

Out of 363 identified studies, three RCTs on halitosis and fixed orthodontic appliances met the inclusion criteria. The risk of bias in the three studies was rated as high and the quality of evidence was rated as very low.

Conclusions/clinical implications

There is a lack of scientific evidence that subjects with fixed orthodontic appliances develop halitosis during treatment. Additional well-conducted RCTs with extended periods of assessment are needed as well as consensus concerning cut-off values for the diagnosis of halitosis.

Efficacy of low-level laser therapy in accelerating tooth movement, preventing relapse and managing acute pain during orthodontic treatment in humans: a systematic review

BACKGROUND

Recently low-level laser therapy (LLLT) has been proposed to improve orthodontic treatment. The aims of this systematic review were to investigate the scientific evidence to support applications of LLLT: (a) to accelerate tooth movement, (b) to prevent orthodontic relapse and (c) to modulate acute pain, during treatment with fixed appliances in children and young adults.

METHODS

To ensure a systematic literature approach, this systematic review was conducted to Goodman's four step model. Three databases were searched (Medline, Cochrane Controlled Clinical Trials Register and Scitation), using predetermined search terms. The quality of evidence was rated according to the GRADE system.

RESULTS

The search identified 244 articles, 16 of which fulfilled the inclusion criteria: three on acceleration of tooth movement by LLLT and 13 on LLLT modulation of acute pain. No study on LLLT for prevention of relapse was identified. The selected studies reported promising results for LLLT; elevated acceleration of tooth movement and lower pain scores, than controls. With respect to method, there were wide variations in type of laser techniques.

CONCLUSIONS

The quality of evidence supporting LLLT to accelerate orthodontic tooth movement is very low and low with respect to modulate acute pain. No studies met the inclusion criteria for evaluating LLLT to limit relapse. The results highlight the need for high quality research, with consistency in study design, to determine whether LLLT can enhance fixed appliance treatment in children and young adults.

Health economic evaluations in orthodontics: a systematic review

BACKGROUND

Economic evaluation is assuming increasing importance as an integral component of health services research.

AIM

To conduct a systematic review of the literature and assess the evidence from studies presenting orthodontic treatment outcomes and the related costs.

MATERIALS/METHODS

The literature review was conducted in four steps, according to Goodman's model, in order to identify all studies evaluating economic aspects of orthodontic interventions. The search covered the databases Medline, Cinahl, Cochrane, Embase, Google Scholar, National Health Service Economic Evaluation Database, and SCOPUS, for the period from 1966 to September 2014. The inclusion criteria were as follows: randomized controlled trials or controlled clinical trials comparing at least two different orthodontic interventions, evaluation of both economic and orthodontic outcomes, and study populations of all ages. The quality of each included study was assessed as limited, moderate, or high. The overall evidence was assessed according to the GRADE system (The Grading of Recommendations Assessment, Development and Evaluation).

RESULTS

The applied terms for searches yielded 1838 studies, of which 989 were excluded as duplicates. Application of the inclusion and exclusion criteria identified 26 eligible studies for which the full-text versions were retrieved and scrutinized. At the final analysis, eight studies remained. Three studies were based on cost-effectiveness analyses and the other five on cost-minimization analysis. Two of the cost-minimization studies included a societal perspective, i.e. the sum of direct and indirect costs. The aims of most of the studies varied widely and of studies comparing equivalent treatment methods, few were of sufficiently high study quality. Thus, the literature to date provides an inadequate evidence base for economic aspects of orthodontic treatment.

CONCLUSION

This systematic review disclosed that few orthodontic studies have presented both economic and clinical outcomes. There is currently insufficient evidence available about the health economics of orthodontic interventions. Further investigation is warranted.

A cost minimization analysis of early correction of anterior crossbite-a randomized controlled trial

OBJECTIVE

Economic evaluations provide an important basis for allocation of resources and health services planning. The aim of this study was to evaluate and compare the costs of correcting anterior crossbite with functional shift, using fixed or removable appliances (FA or RA) and to relate the costs to the effects, using cost-minimization analysis.

DESIGN, SETTING, AND PARTICIPANTS

Sixty-two patients with anterior crossbite and functional shift were randomized in blocks of 10. Thirty-one patients were randomized to be treated with brackets and arch wire (FA) and 31 with an acrylic plate (RA). Duration of treatment and number and estimated length of appointments and cancellations were registered. Direct costs (premises, staff salaries, material, and laboratory costs) and indirect costs (the accompanying parents' loss of income while absent from work) were calculated and evaluated with reference to successful outcome alone, to successful and unsuccessful outcomes and to re-treatment when required. Societal costs were defined as the sum of direct and indirect costs.

INTERVENTIONS

Treatment with FA or RA.

RESULTS

There were no significant differences between FA and RA with respect to direct costs for treatment time, but both indirect costs and direct costs for material were significantly lower for FA. The total societal costs were lower for FA than for RA.

LIMITATIONS

Costs depend on local factors and should not be directly extrapolated to other locations.

CONCLUSION

The analysis disclosed significant economic benefits for FA over RA. Even when only successful outcomes were assessed, treatment with RA was more expensive.

TRIAL REGISTRATION

This trial was not registered.

PROTOCOL

The protocol was not published before trial commencement.

Orthodontic treatment by general practitioners in consultation with orthodontists--a survey of appliances recommended by Swedish orthodontists

The aim of the present study was to disclose the treatment procedures most frequently recommended by Swedish orthodontists for use by general practitioners and to determine whether these recommendations are reflected in the undergraduate dental program in orthodontics at Malmö University. Potential differences between the ortho- dontists' recommendations were also investigated. A questionnaire was sent to 169 consulting orthodontists, seeking their recommenda- tions for appliance therapy to be undertaken by general practitioners: 129 (63 males and 66 females) responded. The Quad Helix was the appliance most commonly recommended for correction of posterior crossbite, a plate with Z-springs for correction of anterior crossbite and the headgear activator for correction of Class II malocclusions. A significant gender difference was disclosed with respect to orthodontists' recommendations for treatment of Class II malocclusions by general practitioners, namely that female orthodontists recommended the headgear activator more frequently than males. However, this difference is most likely attributable to the gender distribution among orthodontists qualifying as specialists during the last five decades: more recently qualified orthodontists are predominantly female. The choice of appliances corresponded well with undergraduate training in orthodontics at the Faculty of Odontology in Malmö.

Stability of unilateral posterior crossbite correction in the mixed dentition: a randomized clinical trial with a 3-year follow-up

INTRODUCTION

The long-term stability of posterior crossbite correction in the mixed dentition has not been sufficiently evaluated. Our aim was to compare long-term outcomes in patients with crossbite correction by using matched controls with normal occlusion.

METHODS

After 35 patients were treated for crossbite with a quad-helix or an expansion plate, we used randomized controlled trial methodology to follow them for 3 years posttreatment. All had fulfilled our pretreatment criteria: mixed dentition, unilateral posterior crossbite, no sucking habits, and no previous orthodontic treatment. Transverse relationships, maxillary and mandibular widths, overbite, overjet, arch lengths, and midlines were registered on the study models immediately before and after treatment and at the follow-up 3 years after treatment. The matched control group comprised 20 subjects with normal occlusion and was compared with the first and last registrations for the treated groups.

RESULTS

At follow-up, changes in the treatment groups were equal and stable. The changes were comparable with the control group. All other changes were minor and had no clinical implications. The long-term effect of crossbite correction on midline deviation was unpredictable.

CONCLUSIONS

If crossbite is successfully corrected by the quad-helix appliance or the expansion plate, similar long-term stability is achieved. However, in treated patients, mean maxillary widths never reached those of normal control subjects.

Correction of unilateral posterior crossbite in the mixed dentition. Studies of treatment effects, stability and cost-effectiveness

Unilateral posterior crossbite of dento-alveolar origin is a transverse discrepancy of the maxillo-mandibular relationship and is one of the most common malocclusions in the mixed dentition. If untreated, the crossbite and the abnormal lateral movement of the lower jaw may strain the orofacial structures, causing adverse effects on the temporomandibular joints, the masticatory system and facial growth. Thus, early orthodontic intervention is usually undertaken to correct the condition at the mixed dentition stage and the orthodontist may choose from a range of treatment methods. The method of choice for orthodontic treatment should not only be clinically effective, with long-term stability, but also cost-effective. The overall aim of this thesis was to compare and evaluate different methods of correcting unilateral posterior crossbite, in terms of clinical effectiveness, stability and cost-effectiveness. The approach was evidence-based; randomized controlled trial (RCT)-methodology was used in order to generate a high level of evidence.

A systematic review concerning early orthodontic treatment of unilateral posterior crossbite

The aim of this study was to assess the orthodontic treatment effects on unilateral posterior crossbite in the primary and early mixed dentition by systematically reviewing the literature. A literature search was performed by applying the Medline database (Entrez PubMed) and covering the period from January 1966 to October 2002. The inclusion criteria were primary and early mixed dentition with unilateral posterior crossbite, randomized controlled trials (RCT), prospective and retrospective studies with concurrent untreated as well as normal controls, and clinical trials comparing at least two treatment strategies without any untreated or normal group involved. Two reviewers extracted the data independently and also assessed the quality of the studies. The search strategy resulted in 1001 articles, and 12 met the inclusion criteria. Two RCTs of early treatment of crossbite have been performed, and these two studies support grinding as treatment in the primary dentition. There is no scientific evidence available to show which of the treatment modalities, grinding, Quad-helix, expansion plates, or rapid maxillary expansion, is the most effective. Most of the studies have serious problems of lack of power because of small sample size, bias and confounding variables, lack of method error analysis, blinding in measurements, and deficient or lack of statistical methods. To obtain reliable scientific evidence, better-controlled RCTs with sufficient sample sizes are needed to determine which treatment is the most effective for early correction of unilateral posterior crossbite. Future studies should also include assessments of long-term stability as well as analysis of costs and side effects of the interventions.

Serum and cerebrospinal fluid concentrations of melatonin: a pilot study in healthy male volunteers

Melatonin was determined in serum and cerebrospinal fluid (CSF) obtained from 13 healthy males lumbar-punctured in the sitting position without preceding bed rest. There was a significant correlation between the levels of melatonin in serum and the CSF. The serum concentration was lower than that in the CSF, a finding that calls in question the theory that melatonin is mainly released from the pineal gland into the bloodstream. In conclusion, serum levels of melatonin in healthy male volunteers, mirror the CSF concentrations when lumbar puncture is carried out using the described technique.

Hydroxypropyl-beta-cyclodextrin inhibits spray-drying-induced inactivation of beta-galactosidase

The single-step, fast spray-drying process may represent a valuable alternative to the multistep, time-consuming freeze-drying process in the area of formulation and processing of biopharmaceuticals. In this study, we tested the use of sucrose and hydroxypropyl-beta-cyclodextrin (HP-beta-CD) as stabilizing excipients in the spray-drying of a model protein, beta-galactosidase. The solutions were processed using a Büchi 190 cocurrent Mini Spray Dryer at an outlet temperature of 61 +/- 2 degrees C. The powders were redissolved and analyzed for catalytic activity, aggregation, chemical decomposition, and thermal susceptibility as observed by high-resolution calorimetry. Spray-drying significantly inactivated beta-galactosidase. Spray-drying beta-galactosidase in the presence of sucrose did not prevent inactivation. However, after spray-drying beta-galactosidase in the presence of HP-beta-CD, or HP-beta-CD and sucrose, full catalytic activity was exhibited on reconstitution. Furthermore, the reconstituted product was unchanged in terms of molecular weight, charge, and thermal stability. These findings are consistent with a hypothesis that the change responsible for inactivation of beta-galactosidase was mainly a monomolecular, noncovalent change, i. e., the formation of incorrect structures, that arose from surface denaturation. This study clearly demonstrates that cyclodextrins can be useful stabilizing excipients in the preparation of spray-dried protein pharmaceuticals.

Increased isotransferrin ratio and reduced erythrocyte and platelet volumes in blood from thermoplastic industry workers

Ten women (aged 31-61 years) and five men (aged 20-59 years) occupationally exposed to welding fumes of polyacetate containing diethylphthalate in a thermoplastic industry were studied. They had been employed 1-33 years (median: 11 years). Seven women (aged 35-55) and eight men (aged 26-73) acted as unexposed controls. The exposed persons showed increased isotransferrin ratio in blood serum and reduced volumes of erythrocytes and platelets in blood.

Separation of different forms of transferrin by isoelectric focusing to detect effects on the liver caused by xenobiotics

Several genetic variants and also isoforms of transferrin differing in carbohydrate structure can be separated by polyacrylamide or agarose gel isoelectric focusing. Numerous blood plasma or serum samples can be analyzed in parallel in each gel. Studies of the heterogeneity of transferrin have already revealed many results of importance to different fields of human medicine. Gene typing can give important and useful information for paternity determination and in forensic medicine. The gene type C 2 seems to have increased frequency in certain malfunctions. Futhermore, functional abnormalities of liver cells can be revealed by determination of the concentrations of transferrin isoforms differing mainly in their carbohydrate parts. The isoforms can be quantified with zone immunoelectrophoresis assay. Thus valuable information can be obtained about important modulated regulations of cell and membrane functions, even when these are disturbed by disease and xenobiotics. The information may be useful e.g. in the detection of individuals suffering from toxic effects, to identify toxic agents and exposure conditions. Studies of house painters revealed that exposure to different types of paints had an effect on transferrin. Determination of the concentration of the isotransferrin with pI 5.7 in blood samples from alcoholics can be used as a marker for the detection of liver dysfunction and for the monitoring of therapy treatments. In addition, by analyzing the isotransferrins a rare genetic abnormality can be detected.

The N-acetylneuraminic acid content of five forms of human transferrin

Five isoforms of human serum transferrin were separated by isoelectric focusing and their N-acetylneuraminic acid content was determined. The forms differed in isoelectric point by about 0.1 of a pH unit with the structural differences situated in the carbohydrate parts. Each form had one sialic acid molecule (NANA) less than the next most acidic form. GLC-MS showed that the most abundant form with isoelectric point 5.5 had two two-branched carbohydrate chains, each having the galactoses covered by terminal sialic acid. The form with isoelectric point 5.4 had one three-branched and one two-branched carbohydrate chain, and all branches terminated with a sialic acid residue. The form with isoelectric point 5.6 had a terminal galactose on one of its two two-branched carbohydrate chains. Comparison of the sialic acid content of the five transferrin forms and their carbohydrate structures showed that some of the forms expose terminal galactose without attracting the asialoglycoprotein receptors on hepatocytes.

Concentration differences in isoforms of transferrin in blood from alcoholics during abuse and abstinence

At least five different forms of iron-saturated transferrin (Tf) from blood plasma can be separated by isoelectric focusing. These transferrin forms differ in the carbohydrate parts, especially the amount of sialic acid. The increased relative concentration of the form with isoelectric point 5.7 (Tf5.7) has been shown to be a good indicator for liver effects caused by alcohol abuse. However, in alcoholics during abstinence the newly formed transferrin has a higher sialic acid content than most of the transferrin already present in the blood. This indicates that the elevated concentration of Tf5.7 with a low sialic acid content, found in alcoholics is not due to a defect at sialylation, but most probably caused by an impaired uptake of sialic acid-deficient transferrin by the hepatocytes due to membrane dysfunction.

Differences among five main forms of serum transferrin

Five forms of human serum transferrin with different isoelectric points were purified by isoelectric focusing in agarose gels. They constitute a set of main transferrin forms in serum of healthy individuals. Their relative proportions are changed in serum from alcoholic individuals, where the more basic of these forms are increased. Tryptic peptides of all forms were compared by high performance liquid chromatography (HPLC) patterns (fingerprint analysis). Two major differences were detected between corresponding tryptic peptides of the five transferrin forms. Some minor differences were also noticed. The corresponding peptides were purified from the main form and analyzed for total composition and amino acid sequence. The peptides with the major differences between the forms were found to be the two with the glycosylation attachment at positions 413 and 611. A minor peptide difference between the transferrin forms contains a product that is explained by incomplete stoichiometry in cleavage of the peptide bond at positions 217-218. Successive loss of sialic acid is compatible with the presence of different transferrin forms, and our results indicate that the main differences between the serum transferrin forms from healthy and alcoholic individuals are in successive changes of the carbohydrate chains attached at positions 413 and 611.

Increased concentrations of a transferrin variant after alcohol abuse

Isoelectric focusing in agarose gel has been used for separation of different molecular forms of transferrin (Tf) in sera and plasma from alcoholics and controls. One special form of transferrin with isoelectric point 5.7 (= Tf5.7) was quantified by using zone immunoelectrophoresis assay (ZIA). This method was also used for quantification of total transferrin (Tftot). Significant differences in the ratio Tf5.7/Tftot between the groups were obtained and the diagnostic sensitivities, specificities and predictive values of positive tests were 100, 97, 93.8%, respectively. Thus the results showed that this principle seems to be much better for detection of alcoholic abuse than currently used assays as gamma-glutamyltransferase, etc. Samples taken on days following hospitalization showed that the Tf5.7 values decreased over a two-week period of abstinence. Possible explanations for the abnormal quotient after ethanol abuse are discussed.