Evidence-Based Orthodontics: an APO Update

Six months ago on August 15, 2012 at the request of PDA Pres. Arturo de Leon, UPCD Dean Vicente O. Medina convened the PDA Cluster on Standards of Care/Clinical Practice Guidelines (SOC/CPG) in conjunction with the latest global impetus in clinical practice: “Evidence-Based Dentistry”. From APO, Robert Eustaquio, Jose Rivera and Roberto Tan, formed part of the Clinical Advisory Group (CAG) for Orthodontics to be part of a larger Methodology Research Group. From systematic reviews, the CAGs from the different specialities would formulate evidence-based clinical parameters, guidelines or standards that would issue forth from the PDA SOC/CPG Council.

Definitions from ADA.org:

Standards are intended to be applied rigidly and carry the expectation that they be applied in all cases and any deviation from them would be difficult to justify. A standard of care indicates that measurable criteria are present and these criteria shall be used in order to arrive at a given level of outcome. Standards say what must be done.

Guidelines are intended to be more flexible than standards. Guidelines should be followed in most cases, but they recognize that treatment can and should be tailored to fit individual needs, depending on the patient, setting and other factors. Deviations from guidelines would be fairly common and could be justified by differences in individual circumstances.

Parameters describe the range of appropriate treatment for a given condition. In comparison to standards or guidelines, parameters broaden the range of professional judgment for the practitioner. They strengthen the ability of the provider to evaluate options and arrive at appropriate treatment.

Initial topics for study were submitted to Dean Medina on September 5, 2012 which was to be tabled during the Oct. 2012 PDA House of Delegates Meeting. While the PDA and its affiliates must contend with institutional inertia, APO members must now evolve with this paradigm shift that has taken place where as clinicians we have shifted from the 20th Century “Age of Science,” to the 21st Century’s “Age of Evidence.”

While before it was sufficient to undergo traditional training, seek continuing education and gain clinical experience to render orthodontic care to a patient, Evidence-based Orthodontics (EBO) now entails an approach to healthcare that requires, “the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to the patient’s oral and medical condition and history, with the orthodontist’s clinical expertise and the patient’s treatment needs and preferences.” The practice of Evidence-Based Orthodontics has evolved to mean the integration of (1) individual clinical expertise with (2) the best available evidence from systematic research, and (3) the patient’s values for personalized orthodontic care. With the explosion of a variety of information in all modes and mediums, Evidence-Based/Augmented Orthodontics seeks a systematic approach to summarize the large volume of literature that health providers need to integrate into their clinical practice. This in a time where the astute patient demands to know the basis for our decisions.

How is that done? When considering the best evidence for treatment for our patients we should rely on the following that is arranged hierarchically in increasing evidence strength:

  1. Clinical opinion/case report,
  2. Case controlled studies,
  3. Cohort studies,
  4. Prospective randomized controlled double blind studies,
  5. Systematic reviews, and
  6. Meta-analysis.

A Key Concept is how to ask questions and the PICO Format lends itself very well to searching the biomedical literature for quantitative studies. It has you taking your question and breaking it down into subcomponents that can then form the basis for a search for evidence.

Asking the right question is a difficult skill to learn yet it is fundamental to the evidence-based decision making process. This process almost always begins with a patient question or problem. A “well-built” question should include 4 parts: referred to as PICO that identifies the patient/problem/population-P, the intervention or exposure, I/E, the comparision C, and the outcomes measured O.

Example: P-In ortho patients I-how does paracetamol C-compared with ibuprofen O-affect levels of pain

Another line of question is, for Cl II malocclusions, should I continue to start in the Mixed Dentition with a functional appliance or heagear, followed by a Phase II course of treatment during adolescence? Or start during adolescence and have BOTH fixed appliances and growth modification with a functional appliance or headgear? Or wait until jaw growth is almost complete and then suggest orthognathic surgical treatment or orthodontic camouflage treatment?

Traditionally, answers were empirically learned while doing, consulting a colleague or mentor, reading journals or textbooks such as Evidence-Based Orthodontics by Greg J. Huang, Stephen Richmond and Katherine W. L. Vig (2011) and Evidence-Based Clinical Orthodontics by Daniel J. Rinchuse, Donald J. Rinchuse and Peter Miles (2012).

Now with the internet, too much information is at our fingertips but we must be discriminatory and precise and while Medline/Embase is bibliographic and lists primary research, second type databases takes the user directly to primary or secondary publications of relevant clinical evidence ex. The Cochrane Collaboration Database of Systematic Reviews, Best Evidence, etc.

One is strongly recommended to go to the ADA Center for Evidence-based dentistry at www.ebd.ada.org where one could find a database of Systematic Reviews which is updated monthly and includes systematic reviews on all oral health topics. Where once before we were asked “show the proof”, as evidence-based orthodontic clinicians, we now must learn to also, “cite the evidence.”

Each APO Member is enjoined to read the following short list:

  1. AAO Clinical Practice Guidelines for Orthodontics and Dentofacial Orthopedics 2008 www.mnortho.org/doc/Clinical-Practice-Guidelines-2008-2.pdf
  2. Collett T. Evidence, judgment, and the clinical decision: An argument for evidence-based orthodontics. Am J Ortho Dentofac Orthop 2008; 133:190-194.
  3. Harrison JE: Evidence-based orthodontics: where do I find the evidence? J Ortho 2000; 27: 71-78 http://jorthod.maneyjournals.org/content/27/1/71.full
  4. Madhavji A, Araujo A, Kim KB, Buschang BH: Attitudes, awareness, and barriers toward evidence-based practice in orthodontics. Am J Ortho Dentofac Orthop 2011; 140:309-16
  5. Papadopoulos MA: Meta-Analyses and Orthodontic Evidence-Based Clinical Practice in the 21st Century. The Open Dentistry Journal 2010; 4 92-123. http://www.benthamscience.com/open/todentj/articles/V004/SI0048TODENTJ/92TODENTJ.pdf