Early orthodontic treatment: More evidence of lack of evidence!
Early orthodontic treatment: More evidence of lack of evidence!
I was planning not to do a blog this week, as I am completely snowed under with work. But then I spotted a tweet from the brilliant Dental Elf (@TheDentalElf) and they have beaten me again to a really interesting paper on early orthodontic treatment. As a result, I had no choice and I have to blog about this now…..thanks Dental Elf! This is going to be a short post though…
This paper is published by a team from the University of London in the beautiful South of England.
R Sunnak, A Johal, P Fleming
Journal of Dentistry epub ahead of print Doi:10.1016/j.dent.2015.02.003
What did they do?
They wanted to determine whether interceptive orthodontic treatment prior to 11 years is more effective that later treatment in the short and long-term.
In their introduction they defined interceptive treatment
“involves the elimination of existing interferences, removing the need for further orthodontic treatment in the permanent dentition or aiming to reduce the severity of the developing malocclusion”.
This is a good neat definition as it can be applied to the classic two phase treatment of Class II malocclusion and also to myofunctional orthodontics. As you know I have blogged about this two issues in the past.
They carried out an extensive systematic review that was confined to randomised trials in children under 11 years old. In brief they evaluated the following interventions;
- Interceptive extractions of primary teeth
- Use of space maintainers
- Correction of cross bites
- Growth modification treatment
- Interceptive treatment with appliances to correct crowding
- Correction of habits
They carried out this review to a high standard using Cochrane methodology.
What did they find?
476 trials were initially identified and following review of the abstracts 30 papers remained. Following further assessment they identified a final sample of 22 studies. This is a large number of trials. 20 of these studies were judged to be at low risk of bias.
The results section was extensive because they evaluated several types of treatment. I do not have space to go through all the results here and I suggest that you try to find a copy of this paper, as it is not open access.
They did a nice discussion of the main findings and I shall outline this. They felt that the review was very broad and this resulted in low sample sizes for each meta analysis. This was further compounded by the selection of a large number of outcome measures and reflect the fact that orthodontists cannot agree on what to measure!
Their overall conclusion was that the area that was most researched was Class II treatment and their conclusions agree with a previously published review, I have discussed this here.
They suggested that there was an overall lack of evidence to prove that early treatment carries additional benefit over and above treatment that commences later. They also pointed out that this does not mean that the treatment is ineffective.
What did I think?
I thought that this was a really good paper that reflects a large amount of really hard, careful work. It was a shame that this was not a Cochrane review with the overall advantage of these reviews being open access and needing to be updated regularly. But it is a lot of hassle to do a Cochrane review and it may not be always possible.
It was interesting that the only findings that they could analyse were concerned with early Class II and one trial of Class III treatment. I was also disappointed that evidence was lacking in most other areas of interceptive treatment. When we consider this finding we must remember that “absence of evidence” does not mean that the treatment is not effective, it means that the evidence to support the treatment is lacking. As a result, it is the clinicians and patient’s decision to undergo early treatment or not. However, it is essential that patients are informed that any proposed early treatment is not underpinned by strong evidence.
Sunnak, R., Johal, A., & Fleming, P. (2015). Is orthodontics prior to 11 years of age evidence-based? A systematic review and meta-analysis Journal of Dentistry DOI: 10.1016/j.jdent.2015.02.003
Emeritus Professor of Orthodontics, University of Manchester, UK.
I see that you were “disappointed that evidence was lacking in most other areas of interceptive treatment.” I certainly agree with your statement. Unfortunately this research is the same worn out traditional thinking and treatment that is still taught in many orthodontic programs. There seemed to be little consideration for why the malocclusion/facial disharmony occurred in the first place, therefore nothing is done to correct such disfunction as airway, maxillary size and form, mandibular relationship, TMJ health and even postural relations.
The mouth is not isolated from the rest of the body. It is time we start understanding the effect our treatment (or lack thereof) in the mouth has on the rest of the body.
I would like to see studies compare long term results where treatment addressed airway problems in a young patient versus treatment of adolescent patients where the airway problem was ignored (or missed) for many years and then treated traditionally (just not my kid!).
HI Kent, thanks for the comment. Yes, I would like to see these studies too, but they have not been done. Have you any suggestions how we do these?
Hello, Kevin and thanks again for another thought provoking review. This is, I believe, at odds with one of your previous reviews. Referring to Thiruvenkatachari B, Harrison JE, Worthington HV, O’Brien KD (2013). Orthodontic treatment for prominent upper front teeth (Class II malocclusion) in children Cochrane Database of Systematic Reviews (11) Other: CD003452 you stated, ” This means that when I see an 8 year old child with an increased overjet, I will explain to them that early treatment will result in a transient increase in their self esteem and that they will be 40% less likely to have trauma than if we waited to provide treatment when they are older. They can then decide. I suspect that we will be providing more early treatment…”
Hi Gerry, thanks for the comment. I suppose that this is my interpretation of the evidence from our studies and the review. The important point is that we can now give the patients and their parents moderate level information on early Class II treatment and let them decide. As a result, when given this information they may feel that it is worth the additional cost and burden of care. Unfortunately, in other areas of early treatment, apart from the interception of impacting canines, the evidence is lacking and we cannot give them this information. In this respect, I would have to let them know that there is no real evidence that early treatment works and it is for them to take the decision. The bottom line is that it is essential to give the patient and their parents all the information that we have, or do not have, and let them take an informed decision. Thanks for your support for my blog!
Best wishes: Kevin
I agree to your notion that the decision makers are patients and clinicians. Though there is no strong evidence ,it does matter for both the clinicians and patients to make the call. My experiences with myofunctional appliances dictate a very vague successful outcome in the long term that is not commensurate with the initial expectation. However, I am still inclined to provide the therapy atleast for the sake of the kid, who is psychologically experiencing low self esteem and forced introversion. Like a temporary bite opening for hassle free bracket bonding, functional appliance does the temporary class 2 interception tactics and nothing more than that.
There are other subtle interceptive corrections that need to be initiated from age 5 onward and I feel orthodontists will be gifted if they could see the kids from that age onward. In a developing country like India with extremes of patients’ affordability, simple and limited interceptive procedures are highly preferential and that may significantly reduce the severity of malocclusion in the later years.
I agree that it would be great if we could intercept malocclusion with simple treatment, but at the moment the evidence that this is effective is just not there. Also please see my other comment on decisions. Thanks for the interesting and thoughtful comment
Perhaps the most quoted Class II, early vs. late, study is the Tulloch study and is widely used by opponents to early treatment. My problem with this and most Class II studies is that they do not differentiate the position of the maxilla relative to cranial base in their case selection. Dental diagnosis alone is wholly insufficient. If the maxilla is dystrophic and compromised in all three planes of space (ie. retrusive in the sagittal plane), then all classical treatments applied, whether one-phase or two, will be inadequate. This is my argument with the Tolluch study: it reaches the conclusion that the results of two inadequate treatments (Bionator vs Headgear) are the same. Do any of the studies in this Cochrane-like review judge anything but the dental results of Class II treatment? Since malocclusion is only a symptom of another imbalance, the only thing this teaches me is that there is no difference in how you can compensate for an imbalance you choose not to treat.
Hi Barry, thanks for the comments. In the cochrane review we did evaluate the cephalometric effects of the treatment and this showed no difference between early and late treatment. In this review, they did not really evaluate ceph changes, this was because the investigators in most of the studies did not use the same analysis. Which is a major difficulty when you carry out a systematic review.
Having practiced orthodontics for 32 years and being a 2nd generation orthodontist, I have been around orthodontics since I began bending retainers in 1962. I entered practice with my father in 1983 when we routinely did 2 phase treatments for Class II patients. After 10 years of practice I noticed that my results were actually better for the single phase cases (eg. less decalcification, less burnout, better appointment cooperation and better final result). I quit doing 2 phase treatment for Class II cases in 1993 and only now do it for psychological distress and excessive overjet where the maxillary incisors are approaching the E-plane. In those cases chances of trauma are significant and should be reduced. Relieving the burden of care for the patient and the parent is a laudable goal. Unfortunately, I believe a major driver for 2 phase treatment is monetary. This also holds true for expansion treatment. It is less work to treat non-extraction, even when facial balance is distorted. I wish our profession would focus more on the patient and less on the practice. To quote my good friend Dr. Lysle Johnston, “Early treatment is a practice management decision, not a biologic decision.”
First, I have enjoyed reading and learning EB from your blog. I’m hearing more and more on early treatment and airways. “Every kid needs expansion (crossbite or not), etiology of most malocclusion etc…”
Any thoughts and any EB literature on the subject?
Thanks
Ron Austin DDS
hi Ron, there is no literature from high level research that suggests that expansion is needed for the treatment of most malocclusions.