Are UK Orthodontists prescribing fewer extractions?
There has been discussion on the role of extractions as part of orthodontic treatment since the dawn of time. This recent survey reveals interesting perceptions of UK orthodontists on their recommendations to extract teeth.
Research has shown that there has been a reduction in orthodontic extractions over the last 30 years. Nevertheless, we do not know much about the factors that may have stimulated this change. This team of investigators based in the UK and Ireland did this study to investigate the following.
“Have the members of the British Orthodontic Society (BOS) made any changes in their referrals for orthodontic extractions”?
“If this has happened, why”?
Fleming et al. Journal of Orthodontics: https://doi.org/10.1080/14653125.2018.1517470
This is an open access paper, which is great.
What did they do?
They did a simple web based survey of all the members of the BOS. In the survey, they asked if the respondents had changed the proportion of patients they had treated with extractions over the last 5-10 years.
If they reported that they had changed. They then asked them relevant questions on the potential reasons for this change. For example, did they use alternative methods of gaining space, had they become concerned about facial and smile aesthetics etc?
They analysed the data by using simple descriptives and a regression analysis to evaluate any factors that they felt influenced their decisions.
What did they find?
They got 208 responses from a total of 1280 members. This was a response rate of only 16%
Overall, 96% of the respondents stated that they felt that they had reduced the number of extractions they prescribed. Interestingly, 30% felt that their crowding threshold for extractions had reduced by 2mm.
When they looked at the possible factors that influenced the perceived reduction. They found that these included concerns about facial and smile aesthetics and increased use of inter proximal reduction. Other reasons were increased use of expansion and proclination of lower incisors.
Their overall conclusion was’
“There is a tendency to reduce orthodontic extractions and an increases use of IPR”.
What did I think?
I thought that this was an interesting, yet small, survey. While the results provide us with some information, we need to consider that there are two issues with this study.
Firstly, the response rate was low. However, the authors pointed out that they had no real reason to think that the responders were different from the non-responders. While I tend to agree, I would be more confident in their findings if they had reported any information on the responders and non-responders.
Secondly, they collected information on the perceptions of the orthodontists. This was not the same as actually recording the extractions that they prescribed. As a result, the perceptions could have been influenced by taking part in the survey and the respondents giving answers that they hoped the investigators would like to hear. We all like to appear to be “cutting edge” and reflect what we consider to be a useful trend in practice.
When I consider these factors, I still feel that the survey does provide us with useful information and a further study is required to measure current practice by recording extraction decisions.
I have given this paper some thought because it seems to reflect a change in practice that has occurred in the absence of evidence on any harmful effects of extractions. To my knowledge there has been no well done research into any harms from extractions in the last 15 years. So why does our practice appear to be changing?
What do I do about extractions?
If I look at my own personal experience, I feel that I have been prescribing less extractions. I certainly, have no hesitation in recommending extractions when there is severe crowding. However, when crowding is mild I have been more willing to align the arches and reassess the aesthetics and the degree of incisor flaring etc. This has usually resulted in treating non-extraction. I, also, do most of my Class II treatment using functional appliances without extractions.
I think that I have followed this approach because I do not like recommending a rather traumatic treatment to my patients unless I am completely certain that this is the best treatment. Furthermore, we all know that space closure is tricky and it is easier to treat non-extraction and I like to keep my treatment straightforward. I cannot help feeling that this the most likely reason for my change.
I am sure that this could lead to a lively discussion on the comment section of this post,
Emeritus Professor of Orthodontics, University of Manchester, UK.