Orthodontics and Evidence-Based Care

Evidence-based orthodontics

What is evidence-based care?

The concept of evidence-based care was pioneered by British epidemiologist Archie Cochrane in the early 1970’s, based upon the underlying principle that treatment offered to patients should be proven to be effective. He and his colleagues devised standards for proper scientific studies, with the gold standard being the Randomized Controlled Trial. Ultimately, these trials can be the basis for the highest forms of evidence, known as Systematic Reviews of the literature and Meta-Analyses. The American Dental Association as adopted the concepts of evidence based care, and it publishes recommendations based upon them. Of course, these concepts apply equally to orthodontics.

Hierarchy of evidence in orthodontics.

Hierarchy of Evidence

What role does evidence-based care play in orthodontics?

Orthodontic treatment planning should be based upon three factors:

  1. What does the scientific evidence tell us about treatment options, and how strong is the evidence?
  2. How does the clinical experience and judgment of the orthodontist factor in with respect to the individual patient?
  3. What are the goals and treatment preferences of the patient or parent?

These three factors may be in balance, but you can imagine a scenario where a patient has no preference or there is little conclusive scientific evidence favoring one treatment option over another for an individual patient. In this scenario the clinical experience of the orthodontist may be the leading driver in selecting the treatment of choice. The key is that the patient is well informed about the nature of the evidence so that the ultimate decision is truly collaborative.

What are some real world implications?

There have been some significant advances in orthodontics of late, many in the areas of dental materials and diagnostic tools. There are also a whole slew of products that come with claims to have made advances in the more “sexy” areas of orthodontics, such faster treatment and allowing of specific movements such as spreading and aligning of crowded teeth in ways that were previously risky or difficult. I get asked about them on a rather frequent basis. In most cases the marketing is well ahead of the evidence, and many claims are eventually proven false. Several of these products increase treatment expense, and in my opinion the marketing claims can put pressure on the orthodontist to compromise. If a certain product actually allows faster treatment of equal quality it should be a fairly straightforward process to show this conclusively in properly designed and conducted studies. Typically early studies are funded by the companies that are selling the product, and this funding bias can affect the conclusions of the researcher. In the end, the orthodontist has to decide whether to promote unproven technology, and if so, to properly inform the patient that quality evidence is lacking.