Orthodontics

1. 1

2. BASED ORTHODONTICS
Dr. Sonal Sahasrabudhe
Post Graduate
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3. Contents
• Introduction
• Definition
• History
• Need for evidence based orthodontics
• Evidence based practice & EBDM
• Clinical scenarios
• Experience Vs Evidence
• Conclusion
• References
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4. 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.
4

5. SO WHAT ELSE CHANGED ?
The Patient
Informed, aware, curious ,skeptical
Definitely more demanding
Doctor-Patient Relationship
A partnership
The need
Treatment on demand, timed,
Needs to fit in with lifestyle
A result
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6. 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.
6

7. 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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8. Dr. Angle’s contributions
Teaching
Invention
of new
appliances
Conducting
clinical
research
Age 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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9. Need for clinical evidence…?
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10. 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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11. • 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
experience
Patient’s
preferences and
values
Best
available
evidence
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12. Health care is all about decision making
Right time
Right intervention
Right patient
Right method
Best results
12

13. How does one arrive at a clinical decision
that is valid, current and applicable to
one’s patient?
Evidence-Based Care
13

14. 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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15. TYPES OF STUDIES
STUDIES
EXPERIMENTAL OBSERVATIONAL
RCT COHORT CASE
CONTROL
CASE
REPORT
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16. Types of Reviews
Reviews
Systematic
Narrative
Syntheses
Meta-analyses
Pooled Estimates
Narrative
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17. HIERARCHY OF EVIDENCE
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18. 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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19. • 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.
19

20. 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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21. Forest Plot
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22. Types of Meta-analysis
22
Random effect analysis
Fixed analysis

23. 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. Intervention
3. Comparison
4. Outcome
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24. • 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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25. • 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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26. • 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 data
3. Estimating a common effect
4. Exploring and explaining heterogeneity
5. Assessing the potential for bias
6. Presenting the results in the form of a table
• FINAL STEP: Interpret the evidence to answer the research
question
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27. 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
27

28. 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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29. 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
29

30. 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
30

31. 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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32. 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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33. How to search for the evidence?
33

34. Sources
Personal experience
Textbooks
Own professional education
Clinical guidelines
Colleagues ,other professionals
Patient
Personal intuition
Trial and error
Supplier ,infomercial literature
Journal articles
Online reference
Unpublished evidence
Overviews
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35. 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
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36. • 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.

37. 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.

38. 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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39. Evidence based decision making
39

40. 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
40

41. • 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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42. Clinical scenarios in Orthodontics
42

43. 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.
43

44. 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.
44

45. 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.
45

46. 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.
46

47. 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
47

48. 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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49. 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.
49

50. 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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51. 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.
51

52. The experienced-based
view
The evidence-based
view
1. Only clinical experience,
and years of it, is relevant
to the practitioner.
2. Denies the usefulness of
science
3. 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
demonstrated
3. Referred research journals
are not biased.
4. Clinical research is adequately
performed and published.

53. 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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54. 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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55. 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
55

56. 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.
56

57. 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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58. 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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59. 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.
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60. Thank You 60