Caries preventive measures in orthodontic practice: the development of a clinical practice guideline

OBJECTIVES

White spot lesions (WSLs) are a side effect of orthodontic treatment, causing esthetic problems and a risk of deeper enamel and dentine lesions. Many strategies have been developed for preventing WSLs, but great variability exists in preventive measures between orthodontists. This study developed statements on which a clinical practice guideline (CPG) can be developed in order to help orthodontists select preventive measures based on the best available evidence.

MATERIALS AND METHODS

A nominal group technique (RAND-e modified Delphi procedure) was used. A multidisciplinary expert panel rated 264 practice- and evidence-based statements related to the management of WSLs. To provide panel members with the same knowledge, a total of six articles obtained from a systematic review of the literature were read by the panel in preparation of three consensus rounds. According to the technique, a threshold of 75% of all ratings within any 3-point section of the 9-point scale regarding a specific statement was accepted as consensus.

RESULTS

After the first and second consensus rounds, consensus was reached on 37.5 and 31.1% of statements, respectively. For the remaining 31.4% of statements, consensus was reached during a 4-h consensus meeting.

CONCLUSIONS

Statements on the management of WSLs derived from a systematic literature review combined with expert opinion were formally integrated toward consensus through a nominal group technique. These statements formed the basis for developing a CPG on the management of WSLs before and during orthodontic treatment.

[Evidence-based clinical practice guidelines in oral care 3. Support for the development of clinical practice guidelines]

Support is an important factor in the implementation of clinical practice guidelines. Data from 5 studies from 1998 through 2013 offer insight into the support for clinical practice guidelines among dentists, orthodontists, dental hygienists and denturists in the Netherlands. In these, attitudes, opinions, knowledge and behaviour were seen as indicators of support. Dentists have an increasingly positive attitude towards clinical practice guidelines. The majority is aware of and uses at least 1 of the guidelines available to them and are in favour of the development of clinical practice guidelines. Orthodontists and dental hygienists have available few such guidelines, but the majority of both groups favour their development. Among denturists, who also have little experience with clinical practice guidelines, there are fewer supporters for their development. All in all, among caregivers in oral healthcare in the Netherlands, support for the use and development of clinical practice guidelines is growing.

[Incisors with a mind of their own]

A 43-year-old man, known to have hypodontia, was bothered by his over-erupted central incisors. After the placement of implants and the accompanying crown- and bridgework, the central incisors appear to be increasingly over-erupted. The history shows that this phenomenon has already been seen in the past. Three mechanisms can be responsible for the over-eruption, specifically: continuous facial growth, over-eruption of both central incisors in the maxilla as a consequence of agenesis of opposing dentition and relapse of the orthodontic treatment as a result of the fact that orthodontic retention is not readily possible. After the central incisors were first cut in such a way that an acceptable incisal line has again been formed, the single-unit fixed dental prostheses on the front elements were replaced with porcelain ones.

[Tooth eruption disturbances and syndromes]

In the tooth eruption mechanism, various disturbances can appear as a result of gene mutations, a consequence of which can be that tooth eruption does not occur. There are 5 syndromes which involve the complete failure of several or even all teeth to erupt, specifically: cleidocranial dysplasia, Gardner's syndrome, osteopetrosis, mucopolysaccharidosis and GAPO syndrome. Some are very rare and will seldom be encountered in a dental practice, but they show how vulnerable the tooth eruption mechanism is. Dentists are generally the ones who identify a tooth eruption problem in a patient. Since syndromes can be associated with other disorders, additional investigation by a clinical geneticist is always important when a syndrome is suspected.

[Facial asymmetry: the benefits of cone beam computerized tomography]

Treatment planning in facial asymmetry is complex and requires precise diagnosis and planning. In the case of a fourteen year old boy with Parry Romberg syndrome, cone beam computerized tomography scanning was used to analyse the asymmetry. Linear, angular and volumetric measurements helped to make clear the extent of the asymmetry, giving the orthodontist and surgeon as well as the patient insight into the possibilities and expectations of treatment. Also the mirror image of the unaffected side superimposed on the affected side was very helpful in this respect. The latter may offer new possibilities for fabrication of individualized alloplastic onlays to further correct asymmetry in the future.

Maintenance of a deep bite prior to surgical mandibular advancement

Adult patients with a Class II skeletal base are often treated by a combined orthodontic and surgical approach. Advancement of the mandible, most often including a bilateral sagittal split osteotomy (BSSO), is preceded by orthodontic alignment and frequently the curve of Spee is levelled. When the chin is prominent, there is a risk of accentuating this as a result of surgery. An option to prevent this is to maintain a deep curve of Spee before surgical advancement. This will result in an opening rotation of the mandible during surgery and thus, a less prominent chin. The aim of this study was to compare, retrospectively, two orthodontic treatment approaches in patients treated by a BSSO. In one group (4 males, 20 females; mean age pre-surgery 29.3 years), the deep bite was maintained (deep bite group) while in the other (3 males, 10 females; mean age pre-surgery 27.1 years) the overbite was normal prior to surgery (level group). Lateral skull radiographs were taken before orthodontic treatment (T0), prior to surgery (T1), and at the end of treatment (T2). Differences between the groups as measured on lateral skull radiographs at T1 and T2 were analysed and quantified using an independent t-test. The results showed that soft tissue pogonion moved significantly further forward in the level than in the deep bite group (P < 0.05). Lower anterior face height and the cranial base-mandibular plane angle increased more in the deep bite than in the level group (P < 0.05 and P = 0.001, respectively). The maintenance of a deep bite prior to mandibular advancement surgery induces an opening rotation of the mandible reducing chin prominence and increasing lower anterior face height post-surgically.

Satisfaction with treatment outcome in bilateral cleft lip and palate patients

The aim of this case-controlled study was to assess satisfaction with facial appearance and function, and health-related quality of life (HRQL) in bilateral cleft lip and palate patients (BCLP). The study sample was composed of adult BCLP subjects and controls matched for age, gender and socioeconomic status. Outcome measures included a self-administered questionnaire evaluating satisfaction with facial appearance, function and HRQL. Bivariate statistics were computed to analyse the association between BCLP status and outcome measures. Forty-three treated adult BCLP patients (mean age 28.2 years, SD 7.8) were compared to 43 controls without clefts (mean age 28.5 years, SD 8.0). Quantitative and qualitative assessment revealed that BCLP patients were significantly less satisfied with the appearance of the upper lip, the nose and nasal breathing. Additionally, satisfaction with facial appearance correlated positively with HRQL. For speech, hearing and drinking, quantitative scores did not differ between BCLP and controls, while qualitative assessment revealed that BCLP patients had considerable problems and concerns with these functions. This study underlines the importance of qualitative assessment of patient satisfaction with treatment outcome to identify individual problems and concerns not revealed by quantitative measures alone.