Identification and appraisal of outcome measures used to evaluate hypodontia care: A systematic review

Tooth agenesis: An overview of diagnosis, aetiology and management

Patients with one or more developmentally absent teeth are routinely encountered in dental practice. Tooth agenesis can be associated with significant functional, aesthetic and psycho-social problems. The present article provides an overview of the prevalence and aetiology of tooth agenesis, as well as the condition's clinical characteristics and management options with reference to the evidence base. A timely diagnosis can facilitate the appropriate planning and management which might not be straightforward, and patient care will likely require multi- and inter-disciplinary input. It is critical that dental care practitioners are aware of the clinical characteristics and management options for tooth agenesis.

Involving young people and parents in decision-making for hypodontia

Involving young people and their parents in decisions about their health care is ethically and professionally the right thing to do. Good decision-making relies on informed, value-based deliberation. Providing the right treatment for people with hypodontia is complex, both technically, in terms of the range of options available, and from a communication perspective. Treatment decisions faced by young people with hypodontia can have lifelong implications and the weight of this is felt both by the patient, who may have limited experience of dental treatment and decision-making, and their parents, who act as advocates. It is important that clinicians understand how they can best share the available evidence and their expertise in a way that can be understood and applied. Clinicians also have an important role in facilitating young people to recognise and communicate their own values, expectations, and ultimately, preferences for treatment. This paper outlines the challenges of navigating information sharing and engaging in shared decision-making specific to hypodontia. A scoping review of the literature by the authors was conducted to identify evidence-based advice for discussing uncertainties, risks and increasing engagement in decision-making. This may be useful to both primary and secondary care practitioners involved in decision-making with people with hypodontia.

Adolescent and Parent Preferences for Hypodontia: Discrete Choice Experiment

Choosing hypodontia treatment requires young people and parents to consider a large amount of information, identify what is important to them, and make trade-offs between options. This study aimed to examine young people and parents' preferences for hypodontia treatment using discrete choice experiment (DCE). This was a cross-sectional survey of young people (12-16 y) with hypodontia of any severity, at any stage of treatment, and their parents. Participants were recruited from NHS Hospitals in England and Wales. A bespoke DCE questionnaire was developed to measure preferences for 6 attributes of hypodontia treatment (waiting time, treatment time, problems during treatment, discomfort during treatment, bite, appearance). The questionnaire was completed 1) online by young people and parents, individually or together, and 2) by child-parent dyads under observation. Preferences were analyzed using regression models. In total, 204 participants (122 young people, 56 parents, 26 dyads) completed the online questionnaire and 15 child-parent dyads completed the questionnaire under observation. The most important attribute in hypodontia treatment was improvement in appearance, but significant heterogeneity was found in preferences. Four distinct groups of participants were found: group 1 (39%): severe discomfort and problems were most important; group 2 (31%): most concerned about improvement in appearance of teeth and improvement in bite; group 3 (22%): appearance 3 times more important than any other attribute; and group 4 (9%): preferences difficult to interpret. There was variation in how child-parent dyads approached decision-making, with some negotiating joint preferences, while for others, one individual dominated. Making trade-offs in DCE tasks helped some people think about treatment and identify their preferences. Appearance is an important outcome from hypodontia treatment, but preferences vary and potential risks and functional outcome are also important to some people. There is a notable level of uncertainty in decision-making, which suggests further shared decision support would be valuable.

Outcome measures in facial prosthesis research: A systematic review

STATEMENT OF PROBLEM

Facial prosthesis research uses a wide variety of outcome measures, which results in challenges when comparing the effectiveness of interventions among studies. Consensus is lacking regarding the most appropriate and meaningful outcome measures to use in facial prosthesis research to capture important perspectives.

PURPOSE

The purpose of the systematic review was to identify and synthesize outcome measures used in facial prosthesis research.

MATERIAL AND METHODS

Electronic searches were performed in 11 databases (including nonpeer-reviewed literature). The citations were searched, and expert societies were contacted to identify additional studies. Inclusion criteria comprised studies of participants with facial defects who required or had received prosthetic rehabilitation with an external facial prosthesis. Exclusion criteria comprised participants with ocular prostheses, case reports, case series with fewer than 5 participants, laboratory-based studies, and studies published before 1980. Study selection was performed independently by 2 reviewers. Discrepancies were resolved through discussion or by a third reviewer. Outcome measures were synthesized with a categorization approach based on the perspective, theme, and subtheme of the outcome measures. Quality assessment was performed with an appraisal tool that enabled evaluation of studies with diverse designs.

RESULTS

Database searching identified 13 058 records, and 7406 remained after duplications were removed. After initial screening, 189 potentially relevant records remained, and 186 full texts were located (98% retrieval rate). After full-text screening, 124 records were excluded. Citation searches and contact with expert societies identified 4 further records. In total, 69 articles (grouped into 65 studies) were included. Studies were categorized as per the perspective of their outcome measures, with the following findings: patient-reported (74% of studies), clinical indicators (34%), clinician-reported (8%), multiple viewpoints (6%), and independent observer-reported (3%). Patient-reported outcome measures included tools to assess satisfaction, quality of life, and psychologic health. Variability in the choice of outcome measures was evident among the studies, with many self-designed, unvalidated, condition-specific questionnaires reported. A greater number of outcome measure themes emerged over time; themes such as service delivery and health state utility have recently been evaluated.

CONCLUSIONS

Over the past 40 years, facial prosthesis research has focused on patient-reported outcome measures. Outcome measures relating to other perspectives have been used less frequently, although new themes appear to be emerging in the literature. Future research should use outcome measures with appropriate measurement properties for use with facial prosthetics.

Space closure versus space opening for bilateral absent upper lateral incisors: what is the duration of orthodontic treatment?

BACKGROUND

Assessment of orthodontic treatment outcomes such as treatment duration in patients with hypodontia are lacking.

OBJECTIVES

To assess the overall treatment duration of cases of bilateral absent upper lateral incisors treated with either orthodontic space closure (SC) or space opening (SO). The secondary aim was to determine factors which influence overall treatment duration.

SUBJECTS AND METHODS

A retrospective cohort study was undertaken within the Orthodontic department at Kings College Hospital NHS Foundation Trust. Consecutively treated patients between 2008 and 2018 with bilateral absent upper lateral incisors were identified from clinic lists, clinical logbooks, and multidisciplinary clinics. All study data variables were collected by a single investigator using a pre-specified data collection sheet.

RESULTS

In total, 52 cases were included, 29 in the SC group and 23 in the SO group. Overall non-extraction treatment was favoured (P = 0.001) with differences in restorations provided post-treatment evident (P = 0.01). Although not statistically significant, the mean overall orthodontic treatment duration was less in the SC group 25.7 months (SD 7.6) compared to the SO group 27.4 (SD 6.1). Overall treatment duration was reduced if treatment was carried out on an extraction basis (-7.02, 95% CI: -11.93, 2.11, P = 0.01) but increased as the amount of crowding in the lower arch increased (0.89, 95% CI: 0.08, 1.71, P = 0.03).

CONCLUSIONS

Within the study limitations, there is no difference in the overall treatment duration between both treatment approaches. Treatment duration is reduced in both SO or SC treatment plans if extractions are undertaken. The presence of lower arch crowding increases the duration of treatment.

Management of patients with hypodontia: What has changed?

This review will consider changes in clinical practice associated with the management of patients with missing teeth and briefly review the evidence base that underpins what we do for them.

Systematic review versus structured critical analysis

Objective: This analysis discusses common problems with systematic reviews (SRs) and presents a novel solution, the structured critical analysis (SCA) that can be incorporated into a SR or used as an alternative literature review design.Methods: A cross-sectional survey of current SRs related to interdisciplinary restorative dentistry was obtained by evaluating 100 current SRs for their self-reported methodological quality and its effect on scientific validity.Results: The preferred reporting items for systematic reviews and meta-analyses protocol (PRISMA) was used in 99/100 SRs, but only 8/100 reported a low risk of bias. High statistical heterogeneity precluding meta-analysis was found in 44/100 SRs. Only 94 paragraphs/100 SRs provided critical analysis.Discussion: Significant problems were found with current SRs that can compromise their reliability as the premier level of evidence for clinical science research. The reader must be aware of these deficiencies to correctly interpret the SR and cannot rely on the format alone.

Development of a Discrete-Choice Experiment (DCE) to Elicit Adolescent and Parent Preferences for Hypodontia Treatment

Objective

Our objective was to develop and test a discrete-choice experiment (DCE) survey to elicit adolescent and parent preferences for dental care for hypodontia (a developmental condition where one or more teeth fail to develop).

Methods

This was a mixed-methods study. Participants were adolescents (aged 12–16 years) with hypodontia and their parents and the dentists providing hypodontia care. Stage one entailed attribute development, as follows. (1) Attribute identification: systematic review of hypodontia literature; interviews with adolescents with hypodontia (n = 8) and parents (n = 8); observation of hypodontia clinical consultations (n = 5); environmental scan of hypodontia patient information resources (n = 30); and systematic analysis of social media posts (n = 176). (2) Attribute selection: stakeholder consultation to develop items for a questionnaire; rating and ranking questionnaire for adolescents with hypodontia and parents (n = 18); further stakeholder consultation. Stage two involved the development of the DCE survey, and stage three included the pre-testing using cognitive interviews with adolescents (n = 12) and parents (n = 8) to assess face and content validity.

Results

The attribute long list included 27 attributes focusing on service delivery and treatment outcome, from which seven ‘important’ attributes were selected for pre-testing. Cognitive interviewing suggested adolescents found the DCE choice tasks challenging to understand; the survey was modified to enhance its acceptability. One attribute was excluded as it showed poor validity with adolescents. Pre-testing suggested DCE choice tasks encouraged thinking and discussion about preferences for treatment.

Conclusions

Including the target respondent group in all stages of DCE development ensured the final DCE survey was valid and acceptable. DCE methods appear to be a useful tool for exploring joint decision making alongside conventional preference elicitation.

Electronic supplementary material

The online version of this article (10.1007/s40271-018-0338-0) contains supplementary material, which is available to authorized users.

Can the current hypodontia care pathway promote shared decision-making?

OBJECTIVE

To determine the extent to which the current care pathway in hypodontia promotes shared decision-making (SDM).

DESIGN

Exploratory cross-sectional study using qualitative methods.

SETTING

Orthodontic department of two NHS teaching hospitals in Yorkshire.

PARTICIPANTS

Young people aged 12-16 years with hypodontia of any severity and at any stage of treatment, and their parents and guardians.

METHODS

(1) Observation and audio-recording of interdisciplinary consultation in hypodontia clinics (n = 5) without any researcher interference; (2) short, structured interviews with young people with hypodontia (n = 8) and their parent (n = 8) using a topic guide to explore themes around decision-making. Audio-recordings were transcribed and analysed using a thematic framework.

RESULTS

Consultations were used as an opportunity for interdisciplinary discussion, information provision and treatment planning. Evidence of good communication was observed but patient engagement was low. The decision to be made was usually stated and treatment options discussed, but time constraints limited the scope for adequate information exchange and assessment of understanding. No methods were used to establish patient and family preferences or values. Interviews suggested parents expect the dental team to make decisions and young people rely on parental advocacy. Despite little evidence of SDM, participants reported satisfaction with their treatment.

CONCLUSIONS

The current care pathway for hypodontia does not support clinicians in the steps of SDM. Recommendations for improving SDM processes include support to identify preference-based decisions, greater access to comprehensive and accessible patient information to enable preparation for consultation, alternative methods for effective communication of complex information and use of preference elicitation tools to aid value-driven decision-making.