Evidence Based Care

This is the beginning of a regular feature of our website. An informational collection aimed at what I would call the “informed orthodontic consumer”. Many of our patients who arrive via the website have really done their homework. They are looking for a true specialist, not a general dentist who dabbles in orthodontics; an experienced practitioner (25 years and counting), and solid academic credentials (3 year Masters Degree program in orthodontics at Ohio State after dental school and a hospital residency). Most of our patients value a conservative approach to orthodontics that provides a great outcome without feeling like they were rushed into treatment.

Other patient’s heads are swirling with questions induced by corporate advertising or from a conflicting treatment plan offered by another practitioner. Achieving great outcomes in orthodontics means blending art and science; function and esthetics. It’s no wonder that the options appear confusing from a patient’s point of view. That is why I rely on what is referred to in the medical literature as “evidence based care”. Although orthodontics is the oldest dental specialty, traditionally most treatment methods were based on opinion gained from experience or relying on gurus within the profession. Over the years this led to hot arguments with little scientific underpinning. The most animated of these discussions within the profession centered on the appropriateness of permanent tooth extractions and our ability to affect the growth of the face to mask defects. More recently, companies such as InvisAlign and Damon stimulated interest in their products with direct marketing to consumers with multi-million dollar budgets and funded research geared to their products. In the last 20-some years the quality of orthodontic research has progressed as a much more reliable tool to assess treatment options. I like to have confidence in the methods that I prescribe and dental research provides that test.

Evidenced based care relies on a hierarchy of evidence to support claims. Rigorous study design helps to eliminate chance occurrences that may look like success. A classic case in point is the controversy over stimulating growth of deficient mandibles with functional appliances. A big overbite (overjet) is a common problem in orthodontic patients and is most often due to a short mandible. There are a myriad of options to correct this problem from headgear, extractions or surgery to the aforementioned functional appliances. As they say in Missouri “even a blind pig finds an acorn once in awhile.” Every orthodontist can show a picture of a patient with a huge overbite who turned out beautifully. Pictures can show that a functional appliance worked great on one particular patient. This is referred to as a Case Report in the literature and is a very weak method of advancing knowledge. Was it lucky growth or did the appliance really work? Recent well designed, prospective, controlled research1 shows that the appliances don’t work in a predictably effective manner to increase mandibular growth.

Practitioners who disparage scientific methods often utilize a case report to show that a particular method works. Their cry is that “it works in my hands”, implying that the reason the research does not confirm the efficacy is that the rest of us are not so well gifted. Some orthodontic cases may be treated successfully by several different methods and some cases may be difficult no matter the method. Paying attention to good research tips the balance in our favor when choosing mechanics for the most predictable outcomes.

The first topics to be covered in this upcoming series are: Growth Modification - Fact or Fantasy; Extractions – Friend or Foe to a Beautiful Face; Early Orthodontic Treatment – What’s to be Gained or Lost; Damon Braces – how do manufacturers claims stand up to unbiased scrutiny?; General dental practice orthodontics – a comparison of education and training; “I have TMJ” we all do and why that’s not such a bad thing

Hopefully this series will give you the dental consumer a good resource for intelligent decision making and it will force me to review some of the most controversial topics for the latest information.

1) American Journal of Orthodontics and Dentofacial Orthopedics Vol. 128, Issue 3, Pages 271-272

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