Specialist orthodontists treat posterior crossbites more efficiently than general dentists
Interceptive treatment of posterior crossbites is a standard treatment. But, is this treatment done better by specialist orthodontists or general dental practitioners?
We all have our preferred treatment to correct posterior crossbites. The most common procedures are either a quad helix or removable expansion plate (unless we are going to go for RME). We also know from previous research that fixed expansion devices are generally more effective that expansion plates.
It is also relevant to consider that either a specialist or a general practitioner can do this treatment. In some countries, for example, Sweden, this treatment is prescribed by specialists, and general practitioners carry out appliance therapy. However, we do not know whether this method of delivery is cost-effective.
A team based in Malmo looked at this question. The EJO published this paper.
Ola Sollenius et al. EJO doi:10.1093/ejo/cjz014
What did they ask?
“What are the costs of quad helix and expansion plate treatment done by specialists and general practitioners”?
What did they do?
They did a multicentre randomised controlled trial with the following PICO;
Participants: Patients in the mixed dentition who had a unilateral posterior crossbite.
Intervention: Quad Helix treatment by specialists or general practitioners
Control: Removable expansion plate treatment by specialists or general practitioners.
Outcome: The Success rate of crossbite correction and costs of treatment.
They did a sample size based upon a meaningful difference in the cost of treatment. They used pre-prepared randomisation with concealment of allocation using sealed envelopes. The assessor who evaluated the success of therapy was blinded to treatment allocation.
They calculated the total cost of treatment. This included the cost of appliances, treatment time, loss of income of parents and travelling expenses.
2 specialists and 17 general practitioners did the treatment. The specialists had 15 years of experience, and the general practitioners had between 1 and 30 years of experience.
What did they find?
110 patients entered the study. They randomly allocated them to the following groups.
- Quad Helix treatment by a specialist (n=28)
- Quad Helix by a general dentist (n=27)
- Expansion plate by a specialist (n=27)
- Expansion plate by a general dentist (n=28)
They carried out an intention to treat analysis that included all the patients.
I have condensed the data into this table.
|Group||Success rate||Retreatments||Number of appts||Remakes||Cost (€)|
The statistical analysis showed that when they looked at overall costs. The most cost-effective treatment was with the quad helix done by specialist orthodontists. This was due to lower costs, less failed treatments and fewer remakes.
Their final conclusion was;
“We recommend that treatment of unilateral posterior crossbite in the mixed dentition is best performed by a specialist orthodontist using the quad helix appliance”.
What did I think?
I thought that this was a fascinating, very well done study. Their methodology was sound, and I could not really detect any issues with this trial. They wrote an excellent discussion that outlined the essential findings and their implications.
It appears that the differences in the cost-effectiveness of the appliances and operator combinations were due to the overall success rates of the fixed and removable appliances. In addition to the number of remakes of removable appliances that had been lost or broken.
I have thought about why these differences occurred. When we consider the use of removable appliances, I believe that it is clear that there will be more treatment failures, because of the deficiencies of removable appliances when compared to fixed.
Nevertheless, it also appears that the specialist practitioners had the same failure rate as general practitioners when they used removable appliances. As a result, any differences in cost are due to the GP removable appliance patients losing or breaking their appliance. Perhaps, the specialists were better than the GPs in motivating and managing their patients. But this is only conjecture.