AcceleDent increases tooth movement by up to 50%…
Does AcceleDent increase tooth movement by up to 50%?
The other day I was looking at an online edition of the AJO-DDO. There was a pop-up from Acceledent that drew attention to their new clinical evidence. I thought that I should have a look at this again….
This is the link to their page. You will see that they specifically mention three RCTs that support AcceleDent.
I decided to look at these trials. I have reviewed two of these before. The first I did was the AcceleDent sponsored study run by an AcceleDent consultant published in Seminars in Orthodontics. In my post, I pointed out that, in my opinion, this study was significantly flawed and I still cannot understand why the journal editor agreed to publish this paper. Another paper investigated pain. Again, I felt that this was significantly flawed, as the study did not include a placebo.
I have also posted on other studies by Miles and Woodhouse. These were much better studies that showed no effect of AcceleDent. However, AcceleDent and their Key Opinion Leaders do not appear to quote them..
The study they mentioned was published in the Angle Orthodontist and I must have missed it last year.
Vibratory stimulation increases interleukin-1 beta secretion during orthodontic tooth movement
Chidchanok Leethanakul et al
The Angle Orthodontist: January 2016, Vol. 86, No. 1, pp. 74-80.
They did this study to investigate the levels of pro-inflammatory molecules in the gingival crevicular fluid after the application of a vibratory force.
What did they do?
They did a split mouth randomised trial. The PICO was;
Participants: 15 patients (11females, 4 males) aged 19-25 years having orthodontic treatment that needed canine retraction. The operators retracted the canines using a power arm and elastics.
Intervention: They selected the right or left canine to have vibratory stimulation from a powered toothbrush (NOT ACCELEDENT).
Comparison: Split mouth. Toothbrush vs no intervention.
Outcome: Tooth movement
They gave no information on method of randomisation apart from saying that the right or left canine was selected by the operator. They also did not provide any information on allocation concealment or sample size calculation. These are fundamental problems in the reporting of a trial.
When I looked at their method of measurement this was not clear. They stated that the accuracy of their measurement was 0.01mm but did not let us know how they calculated this.
What did they find?
I will only look at the tooth movement data. I have put this in this table along with the 95% CIs.
| Paper | Type of study | Outcome | Result | Paper quality |
|---|---|---|---|---|
| Woodhouse | RCT | Rate of alignment | No difference | High |
| Miles | RCT | Rate of alignment | No difference | High |
| Pavlin | RCT | Canine movement | 0.37mm/month | v.low |
| Leethanakul | ? | Canine movement | 0.38mm/month | v.low |
| Lobre | RCT | Pain | Less pain in short term with AcceleDent (no placebo) | low |
Therefore, within the severe limitations of this study, they found a significant difference in the amount of tooth movement. This was 1.15mm over three months or 0.38mm/month.
What did I think?
In my academic opinion, I felt that this study was significantly flawed, for the following reasons;
- There was no sample size calculation.
- The sample size was very low. This means that the effect size may be subject to individual variation.
- The investigator “chose” the canines for the intervention/control. This does not appear to be an RCT.
- There was no allocation concealment.
- They provided limited information on the method of measurement and no information on how they carried out an error analysis.
- We also need to consider the effect size. This was 1.15 mm over three months, that is 0.38mm/month. I am not sure if this is really “speeding up” tooth movement.
Finally, they did not use AccelDent (cost $800-1000) they used a tooth brush (cost $80). I know what I would use…
Summary
I have put together a summary table of the evidence from my posts on this subject.
| حركة الأسنان | الفروقات | |
|---|---|---|
| مجموعة المراقبة | 1.77 (95% CI 1.71-1.8) | 1.15 (95% CI 1.00-1.2) |
| مجموعة فرشاة الاهتزاز | 2.85 (95% CI 2.7-2.9) |
I can only conclude that we do not know if AcceleDent has an effect on tooth movement. However, AcceleDent are correct in their claim of an increase of “up to 50%”. My broadband provider claims up to 200Mb/s…but I get much less. However, you need to decide on the effect size and the strength of evidence and then decide if you want to recommend (sell) this device to your patients.
I have now posted on this subject several times. I think that one of the most interesting features of the papers that I have analysed is that the higher quality studies published in the AJO-DDO and Journal of Dental Research do not show an effect. Whereas, those that show a small effect are significantly flawed and published in lower impact journals. However, this is clearly an editorial decision and I am not going to comment.
Finally, I can fully understand why AcceleDent do not quote the evidence that does not support their product. It is the role of the salesman to sell their product and it is our role as clinician scientists to evaluate their claims. However, the silence from the clinicians selling AcceleDent to their patients and the Key Opinion Leaders is deafening.
I also wonder if it is time that the specialist societies made a statement on the various methods of “moving teeth faster”. The AAO did this for self-ligation and took a lead in carrying out this type of work. Is there anybody out there?
Emeritus Professor of Orthodontics, University of Manchester, UK.
Isn’t there veracity rules for advertising? We need to smarten up as orthodontists. Problem is they market direct to public. Thanks for material to give to any patient that may ask for this.
Kevin
Thank you for this excellent summary. I have stated the same both at the AAO and just this month at the Fred West Lecture at UOP. My conclusion however is slightly different in that clinically in my practice I see patients who use Acceledent finishing faster. These patients actually have requested and paid for it as an alternative to interdental perforations to achieve shorter treatment times. My conclusion is that it is an expensive compliance motivator as patients who pay extra to finish faster actually wear their aligners as prescribed. Ironically, you will not be surprised that when we included them gratis as part of treatment they often went unused.
Similar experience Dave. I have seen excellent clinic results in my practice that include finishing faster (ie: Adult full molar Class II with Forsus 15 months, good stability, no notable root resoprtion, or Adult PM exo 18 mo’s etc) less discomfort, happier/more motivated patients, less OH problems. It’s non-invasive and improves my patient’s treatment experiences with little risk. I use it with most success in combination with Active Self ligating brackets and a shorter AW recall schedule… The flaw in many of the “it doesn’t work” studies, that non-users don’t seem to notice, is they are typically using twin brackets and using the same recall schedule for the control and test groups…. given that clinical scenario, the question I ask is how are we to note difference in tooth movement rates when we only look at the patient every 6 weeks?…. what if all of the movement happened in the first 3-4 weeks then the system, by design, passivates and sits quietly waiting for the clinician to notice? When using Accel in my practice, I change the way I treat these patients. It’s been successful for me and the only negative outcomes that I worry about are cost to patient (I pass on the full cost, no mark up, no absorption) and compliance (which is generally quite good considering) – the value to me is not in the “sales” as I make nothing on it and could argue that there is some financial risk in the inventory, the value is the in the clinical benefits noted above, so I guess that goes to say I am a “believer” and i see a benefit for my patients.
HI Marguerite, thanks for the useful comments. I am interested that you treat the AcceleDent differently. I assume that this means that you see them at more frequent intervals. if this is the case, then we need to consider that this may speed up the tooth movement. This is, therefore, an operator effect, which may be more important than the AcceleDent?
True, but I don’t see the outcomes that one might expect with “too fast” movement – root shortening, discomfort, difficulty seating wires etc.
Marguerite, You mention the use of twin brackets implying it is a flaw in the study design and proven slower. The studies on SL brackets have found no benefit in terms of treatment time or they may actually be slower by 2 months (Papageorgiou Eur J Orth 2013 https://doi.org/10.1093/ejo/cjw041). When evaluating canine retraction with SL brackets, a study by myself (Miles AJODO 2007 Aug;132(2):223-5.) and Jack Burrow (Angle 2010, Vol. 80, No. 4, pp. 626-633) found the SL brackets marginally slower which Jack attributed in his article to the narrower SL brackets with the wider Twin bracket being more efficient (due to binding with tipping in narrower brackets). As to time, in my recent paper in the AJODO (2016 150, Issue 6, Pages 928–936) I took models at 5, 8 and 10 weeks and at no time point was there any difference in the arch perimeter or irregularity. It was not aligned sufficiently to change to the 2nd archwire at 5 weeks and therefore could not have mattered when you change the wire. If you have data for 3 or 4 weeks to show a difference this would be fantastic to see published. The data I have on archwire changes (to be published) demonstrates no difference and the time to the working wire is shorter than other clinical reports using vibration that claim to have reduced their appointment intervals. In my case I use 18 slot brackets so perhaps the case could be made that 18 slot is more efficient than 22 slot rather than an effect of vibration – but that requires another study!
“Money changes everything.” Cyndi Lauper, 1984
Thanks Kevin. Couldn’t agree more.
And Frankels grow mandibles. The more things change the more they stay the same
It is several years since AcceleDent opened a UK subsidiary. The HQ and warehouse was based in Llanelli, Carmarthenshire, Wales. I think a couple of local professional customers were enrolled (I was not one of them). The local (UK wide?) representative told me they had a number of UK orthodontists as customers, mainly London based, especially west London. Since the collapse of the Llanelli based operation, I have not heard of it until now and had thought the idea was defunct.
Is it a medical device – in which advertising must prove efficacy – or a consumer product – in which only safety is required. I know what I feel.
The rate of optimum tooth movement, as widely quoted even in Undergraduate text books is 1mm per month for canines. In this background, if we look at the results tabled, test group shows 2.85 mm in three months, matching the optimum rate. While, it appears, the control group had impediment to attain this rate-1.77 only in three months. My take on it(subjective)is that, AccelDent might have been effective in removing the impediment to ‘normal’ tooth movement in the study quoted ?
We did 2 prospective studies through University of Illinois measuring treatment speed. One with AcceleDent and Invisalign and the other AcceleDent and Suresmile. Both studies will be published. The result is the same. No measurable difference in speed with AcceleDent. There was a difference in discomfort (AcceleDent helped).
Thank you Kevin for the Interesting discussion.
It would be interesting if the orthodontists favoring Accel could somehow set up randomized trials in their practices to compare treatment efficiency between patients using Accel vs sham Accel.
Nick