What do general dentists think about managing bonded retainers?
One of the most popular forms of retention is the bonded retainer. These require monitoring over a long time. General Dental Practitioners are often asked to do this monitoring. But what is their knowledge and feelings about being asked to take on this role? This new paper provides us with helpful information.
I used to place a lot of bonded retainers. However, I became concerned that my clinics were filling up with retainer reviews. I then took the step of discharging my patients and asking their general dentists to monitor their retention. This method seemed to work for a while, but then I picked up that many dentists were not happy to do this. Their main reason for this unhappiness was that they were concerned that they did not have the expertise or knowledge to monitor fixed retention. This study is about general dentists knowledge and perception of the management of bonded retainers.
A team from Strasbourg, France and Groningen, the Netherlands, did this interesting study. The American Journal of Orthodontics published the paper.
How do general dental practitioners perceive and deal with orthodontic bonded retainers?
Frederic Rafenbeul et al
AJO-DDO Advance access: DOI: https://doi.org/10.1016/j.ajodo.2020.12.018
What did they ask?
They did the study to:
“Determine Eastern French GDPs management of orthodontic bonded retainers, knowledge of their side effects and willingness to take part in long-term follow up”.
What did they do?
They did an online questionnaire survey. The questionnaire was in four parts;
- Demographic information about the dentist
- Their clinical management of bonded retainers
- The GDPs knowledge of bonded retainers side effects.
- Communication between the dentist and the orthodontist.
They did a sample size calculation. The results showed that they needed 218 respondents to obtain a 95% confidence interval with a 6% margin of error. Consequently, the investigators randomly selected the 218 dentists from a larger sample of 1433 dentists who were practising in the Alsace region of France.
They contacted the dentists in May 2019 and asked them to complete the anonymous online survey. The team followed this up with two reminders that they sent 1 and 3 weeks after the initial contact.
What did they find?
Seventy-one out of the 218 dentists completed the questionnaires (a response rate of 32%). In addition, the local University in Strasbourg had trained 90% of the respondents.
I have looked at the large amount of information that the authors presented and selected what I think are the most important findings. These are:
Retainer management
- 73% estimated that they saw between 2 and 10 patients a week who were wearing retainers.
- 78% checked the retainers during appointments.
- 97% had an experience of a patient with a debonded retainer.
- 47% regularly repaired retainers.
- If there had been tooth movement, 91% referred the patient back to the orthodontist.
- When a retainer failed, 54% felt confident to carry out a repair. Notably, 35% thought that they were not competent.
- Bonded retainer side effects
- 81% were unaware of the third-order movement of teeth if the retainer twisted.
Communication and responsibility
- Notably, only 10% of the dentists were willing to accept the transfer of responsibility for long term retention.49% thought the orthodontist should retain responsibility.
- The main reasons for this were lack of knowledge (72%) and financial issues (61%).
- Importantly, their findings were similar to other studies that have looked at this problem.
Their overall conclusions were:
“French GDPs knowledge and training on the management and deleterious effects of retainers was inadequate. As a result, only a minority of dentists were willing to provide long-term follow up of bonded retainers”.
What did I think?
Firstly, this study looked at a very clinically relevant question. Importantly, the investigators pointed out that the responsibility for long term retainer management is a significant problem. It is challenging and possibly inefficient for orthodontists to review all their retainers over what could be many years. This is particularly true for the concept of lifetime retention (which cannot practically occur).
Alternatively, we argue that the responsibility for bonded retainers could lie with the patient. However, this relies on them monitoring their retainers and contacting their orthodontist when they had problems. While I am sure that some may be able to do this. There is no doubt in my mind that many will not have the motivation or skill to manage this.
It is also relevant that 72% of the sample felt that they did not know how to monitor bonded retainers. As a result, retention monitoring may be considered to be outside their scope of practice. However, this finding really means that orthodontists should not simply expect dentists to carry out this role. Indeed, if we blindly refer back to the dentists for retention monitoring, we may be acting unprofessionally.
Solutions?
This is clearly a long term problem. The authors have put forward some solutions. These are sensible. They suggest that we improve communication about fixed retention with our referring dentists. In my view, this would be the quickest fix. Another is to train student dentists in retention management. We could fit this into the curriculum. Unfortunately, it would be many years before this had an effect on the real world of practice. As a result, perhaps we need to consider increasing communication with our referring dentists.
Shortcomings?
Unfortunately, like all studies, there are shortcomings. The major one that I spotted was the response rate was low at 32%. This is common for online surveys. We, therefore, need to consider if this has introduced bias into the results. One method of evaluating this is to obtain information on the non-responders. Investigators can then make a comparison between the responders and the non-responders. Unfortunately, the investigators did not do this. Furthermore, I am also concerned that the response rate influenced the power of the study. This would clearly affect our degree of certainty in the findings.
As a result, we need to consider the effect of these problems when we interpret the results.
Emeritus Professor of Orthodontics, University of Manchester, UK.
”It is challenging and possibly inefficient for orthodontists to review all their retainers over what could be many years. This is particularly true for the concept of lifetime retention…”
“we argue that the responsibility for bonded retainers could lie with the patient. However, this relies on them monitoring their retainers and contacting their orthodontist when they had problems. While I am sure that some may be able to do this. There is no doubt in my mind that many will not have the motivation or skill to manage this.”
The standard of care in the United States calls for the proper monitoring of chronic health conditions. I understand that malocclusion is not critical health but it is chronic with relapse a lifetime issue, hence, “the concept of lifetime retention.” The article is mainly concerned about bonded retainers but the larger issue is really relapse. What about posterior relapse, ill-fitting removable retainers etc.? Solely relying on the patient could easily be considered do-it-yourself — not a good idea in this day and age in the USA. In a doctor-patient relationship, there is only one expert — the doctor.
A suggested long-term solution is to include retention maintenance in pre-doctoral education. I suggest a short-term solution may be local orthodontic societies giving GP continuing education courses on retention including repairing, possible replacement, and most important, monitoring for their patient’s benefit. The GDP office that advises their patients that monitoring their retainers is an important part of their recall exam is adding more value to that appointment and an incentive to keep the appointment. My experience over 45 years is that a successful GP practice has a very successful recall system. Working with the GDP may be a win-win for everybody.
I hated bonded retainers and much preferred the vacuum formed “Essix” type worn at night for 6 months then intermittently. This study confirms what most of us in the UK probably suspected. Also, do GDP’s in the UK get a fee for repairing a broken bonded retainer? The systems on the Continent are different.
So, the old retention/stability conundrum crops up yet again! I agree with you and the majority of NW France’s GDPs that supervision and maintenance of long-term fixed retainers should be the responsibility of the orthodontist, though simply as a matter of responsibility being placed where it belongs.
The solution could be in the proper orthodontic training of undergraduate dentists in the first place (a subject long since absent from the dental curriculum, and greatly missed). In addition, they should be taught the true nature of the aetiology of malocclusion.
Conventional orthodontists have as yet failed to identify this. They are still stuck with genetics as the main cause without considering the massive effects of environmental factors, and they mistakenly see malocclusion as the issue to be treated. Many of us now understand that the teeth are simply the passengers in the process of cranio-facial growth. They are not the problem – they are the result of the problem, be it cranial, muscular, habitual or developmental, most probably a combination. Teeth do not have the power or the ability to cause a malocclusion; they are simply carried along by skeletal growth and development, and they end up where this process places them. If the causative factors are not correctly identified and addressed, relapse is inevitable, and no amount of fixed retention will do the job, other than short-term.
The recommendation by the BOS, backed by the GDC, that only life-long retention will provide adequate post-treatment stability is a dreadful failure by an entire profession, unequalled in any other sphere of health care I can think of; can you imagine a surgeon telling his patient “I can fix your knee joint for you, but you will be in crutches for the rest of your life”.
How many orthodontic patients or parents sign up for treatment if the fully-informed consent form actually states their (possibly very expensive) treatment is unlikely to last more than 10 years even with ‘permanent’ retention? But with recognition of the true aetiology, fixed retainers would be a thing of the past.
if only what you say was true
i have yet to see any published or presented information (without bias or lies) that shows guaranteed stability with any form of intervention
I agree entirely, but the fact that we do not have the evidence does not mean it is not true, only that as yet no one has done the necessary study. Any offers?
If we do not respond appropriately to (relatively) new ideas, the profession will never advance. In fact it will go backwards as the rest move onwards. Thinking outside the ‘comfort zone’ box should rightly be challenged, but it should also be appropriately examined and investigated. Not to do so is to deny our patients possible advances and advantages. Let’s face it, post orthodontic stability is, in general, a failure.
True, but if there is no evidence you do not know if your statement is false or true. If you believe you are correct then you should have treated many cases over your career. Why not publish them. We will all be able to look at your results and see the way forward. It is up-to those who propose a “new idea” to demonstrate to those stuck in the past that they are correct. As ever the test is put up or keep quiet. Lets see your evidence
Steve, I would love to be able to respond to your challenge, but I retired nearly 20 years ago having learned about all this aetiology stuff in my last very few years, so I had a) only a few relevant cases, and b) I no longer have any access to their records. However, I still live in the village where I practiced for 25 years and frequently come across my ex-patients; I can honestly say that the only signs of orthodontic relapse I see are in those patients I treated with extractions, the way I was taught, prior to my learning the reality of orthodontic aetiology, including my own son!
I will ask the orthodontic members of BSSCMD if they would be willing to take part in an appropriate retrospective study.
A failure of education
All graduating dentists should know how to maintain and repair a bonded retainer. It is not difficult and is much easier than placing a direct composite.
In my hospital department I used to fit approx 300 per year and was happy to maintain them, NHS commissioners have specifically removed our ability to provide ongoing care of retainers
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Clinical training in repair of bonded retainers will be more useful than spending time learning the Krebs cycle, renal physiology and embryological development of the brain.
Alternatively there could exist a trained therapist who is able to work independently and take personal referrals.
Orthodontic therapists I work with would be able to repair a bonded retainer better than most dentists and at a lower fee.
This is such timely blog!
As a periodontist I am seeing an increasing number of cases that are sent for recession management where the ortho retainers have become “active” and have torqued the teeth out of the alveolar housing. I have a small case series that I hope to present at BOS.
My feelings are that this is likely due to “trauma” to the wire rather than an unravelling of the twist flex wrist as the root movement I have seen has been both labial and lingual but all involve a torquing of the apex out of the bone leading to recessions.
Whilst these cases are rare, I have had around 8 in the last 3 years (baring in mind not many last year due to lockdowns) but talking to others, they are seeing the same too.
Like most dentists, understandably you are thinking “teeth”. Try thinking ‘bone’ and you may have a different perspective on this. Personally, I cannot imagine how a passive retention wire, fixed or removable, can become active in any real sense, but I may be wrong.
Thanks, a team in Germany did a FEA study many years ago showing that mesially directed occlusal forces can result in third order movements.
These movements typically arise when a patient is given dual retainers (removable and fixed) but stops wearing the removable