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.
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:
- 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.
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.
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.