Felicity Borrie

Early correction of anterior crossbites: a systematic review

Objectives To identify the appropriate treatment for the correction of anterior crossbite. Design Systematic review. Data source A search strategy was developed along with inclusion criteria and run in Scopus, Medline, Cochrane Library, EMBASE and psychINFO databases. Selection criteria Children in the primary or mixed dentition with an anterior crossbite affecting one or more incisors, and no underlying skeletal class III discrepancy. Data selection and extraction All potential articles were checked against the inclusion criteria independently, and in duplicate by two investigators. Reference lists were checked for relevance and possible inclusion. Manual data extraction was carried out using a standardized format and agreed by the two investigators. Outcomes Time taken to correct the crossbite and treatment duration. Data synthesis The data were arranged by type of study and further subdivided by treatment type. Results A total of 499 articles were identified following electronic and hand searching and checking reference lists. Following examination of titles, abstracts and, where applicable full articles, 46 articles were included. Owing to the low levels of evidence, no statistical methods were employed. Conclusion This review has highlighted the lack of high quality evidence for the management of anterior crossbites in children. Although the level of evidence is low, there is similarity in the length of time it took to successfully treat anterior crossbites using similar treatment modalities. High level studies are required before definitive conclusions can be made.

Should I eXtract Every Six dental trial (SIXES): study protocol for a randomized controlled trial

BackgroundExtraction of lower first permanent molars in children is common. There is uncertainty among clinicians as to whether a ‘compensating extraction’ (removal of the upper first permanent molar to prevent it over erupting) is necessary despite current guidelines recommending this. As a result, unnecessary dental extractions may be carried out or children may be failing to receive extractions required to achieve optimal long-term oral health. In addition, the decision to extract fewer or more teeth affects management options (local anesthetic injections alone, inhalation sedation or general anesthesia) needed to support the child with the surgical procedure(s).The SIXES (Should I eXtract Every Six) dental trial investigates clinical effectiveness and quality of life for conventional treatment (following the guideline of compensation extraction of the upper first permanent molar) compared with the alternative intervention (removal of lower first permanent molars but no extraction of the upper).Methods/DesignThis is a multicenter, two-arm parallel group randomized clinical trial. Allocation will be web-based randomization. Practitioners in primary and secondary care settings, reflecting the points of presentation and treatment of eligible patients, will recruit 400 children, aged 7 to 11 years requiring extraction of lower first permanent molars but who have upper first permanent molars of good prognosis. Baseline measures (prior to treatment) and outcome data (at one and five years, or when the patient reaches 14 years of age) will be assessed through study models and child/parent questionnaires.The primary outcome measure is degree of tipping of the lower second permanent molar, (favorable outcome is tipping less than 15°).The secondary outcomes are type of anesthetic/sedation used, residual spacing (between lower second premolar and second permanent molar), orthodontic treatment requirement, quality of life, and over-eruption in the intervention group. Assessors will be blinded where possible.DiscussionSIXES dental trial investigates whether compensating extraction of upper first permanent molars should be carried out following loss of lower first permanent molars. Currently dentists and orthodontists face a dilemma in clinical decision-making, relying on the lowest level of evidence - expert opinion. SIXES will provide evidence to support decision-making and inform practices and may result in reduced tooth extractions.Trial registrationClinical Trials.gov Identifier: NCT01591265

A Scottish cost analysis of interceptive orthodontics for thumb sucking habits

Objective There is a potential cost saving to be made within the NHS by providing simple interceptive treatment rather than comprehensive treatment at a later date. The focus of this study is to determine the size of this potential cost by looking at the cost to NHS Tayside for the provision of interceptive treatment for cessation of thumb sucking and where this has been unsuccessful (or not provided) the costs of correction of the associated malocclusion. Design A cost analysis is described, investigating the costs of treatment solely to the NHS, both in the primary and secondary setting. Methods Three potential treatment pathways are identified with the costs calculated for each pathway. The actual cost of providing this treatment in NHS Tayside, and the potential cost saving in Tayside if there was a change in clinical practice are calculated. Both discounting of costs and a sensitivity analysis are performed. Results The cost to NHS Tayside of current practice was calculated to be between £123,710 and £124,930 per annum. Change in practice to replace use of a removable with a fixed habit breaker for the interceptive treatment of thumb sucking reduced the calculated cost to between £99,581 and £105,017. Conclusion A saving could be made to the NHS, both locally and nationally, if the provision of a removable habit breaker was changed to a fixed habit breaker. In addition, increasing the proportion receiving active treatment, in the form of a fixed habit breaker, rather than monitoring, would appear to further reduce the cost to the NHS considerably.

Mandibular advancement appliances for treating sleep apnoea/hypopnoea syndrome

Study designRandomised controlled crossover trial.InterventionSixteen participants (13 men and three women) with mild to moderate OSAHS, diagnosed using polysomnography (PSG), were recruited from a sleep clinic. To be included, participants had to have 20 or more teeth (sufficient to provide retention for oral appliances), have had no previous OSAHS treatment, been unable to tolerate nasal continuous positive airway pressure and be free from caries, periodontal disease, temporomandibular joint (TMJ) pain or movement limitations. One-night mandibular advancement titration was carried out using a custom made temporary dental appliance to reach each individuals pre-determined maximum voluntary advancement value. Participants were given one week to acclimatise. Two different MAAs were made to this titrated value for each participant; the SILENT NITE (a two-piece MAA in flexible trays connected by two plastic bars to maintain mandibular advancement) and a one-piece resin-made activator appliance which was retained by posterior tooth clasps. Patients were ‘randomly divided’ into two groups and wore one or other appliance as allocated for three months. Following a two week washout period, they then wore the other appliance for a further three months.Outcome measureSubjective measures were recorded pre- and post treatment using Epworths Sleepiness Scale and an unspecified Snoring Scale. Preferences, compliance and side effects were assessed through interviews with patients and their families. Pre- and post treatment objective measures were taken using a variety of PSG results which were manually scored by a blinded operator (these included EOG, ECG, supplemental EMG, nasal-oral airflow, abdominal and chest respiratory effort, ECG rhythm). Cephalometric radiographs taken pre- and post treatment were scored by a single examiner for upper airway space diameters.ResultsBaseline measures for both BMI and titrated distances for mandibular advancement were similar for both groups. Daytime performance (ESS) and snoring (SS) showed significant improvement for both MAAs during treatment but there were no significant differences between the appliances. Out of the 16 participants, seven preferred the monoblock appliance, two preferred the two-piece and seven had no preference. All patients finished treatment and stated full compliance despite some of the participants experiencing side effects; two had ulcers for several weeks at the start of treatment, four experienced TMJ pain, three complained of muscle discomfort and four felt some dental discomfort. PSG showed that total sleep time did not differ pre- and post treatment and sleep efficiency increased for the monoblock appliance only. Both appliances showed improvement in AHI, AI and Hypopnoea Index, but the monoblock had a more statistically important improvement for AHI and AI. Upper airway space diameters were increased with both MAAs but there were no significant differences between the appliances.ConclusionsBoth the monoblock and the SILENT NITE appliances were effective at reducing the severity of symptoms of OSAHS. The monoblock, however, offered some advantages over the two-piece appliance in achieving a greater improvement in Apnoea Hypopnoea Index and Apnoea Index and being preferred by most patients.

Breastfeeding and occlusal development

Data sourcesPubmed, Embase, Scopus databases and New York Academy of Medicine Grey Literature Report. There were no restrictions on language and publication dates.Study selectionTwo reviewers selected both prospective and retrospective studies of children who had either been exclusively breastfed or were mixed breastfed; who were in either the primary or mixed dentition, and malocclusion was assessed. The following malocclusion traits were included; Class 2 molar, open-bite, non-spaced dentition and posterior crossbite.Data extraction and synthesisData were extracted including type of dentition, type of malocclusion, breastfeeding data collection method, results, breast feeding malocclusion odds ratio (OR) and quality of the article. The ORs of associations between different lengths of breastfeeding and the various malocclusion traits were calculated.ResultsThirty-one studies were included in a qualitative synthesis, nine in the quantitative analysis. All studies were observational, a majority examining malocclusion in the mixed dentition. Two studies looked at associations between no breastfeeding and posterior crossbite, finding children not breastfed presented 1.7 times more posterior crossbite than those breastfed for between one and six months (OR = 1.70 CI 2.01-2.39). ORs were calculated for exclusive breastfeeding and posterior crossbite with different duration of breastfeeding, and duration of breastfeeding and posterior crossbite. With regard to open bite and breastfeeding the OR=1.76 (CI 0.55-5.61) comparing those who were breastfed for less than or more than six months. Children breastfed for up to six months presented 1.25 times more Class 2 molar relationships than those breastfed for over six months. Children breastfed for up to six months presented 1.73 times more non-spaced dentitions than those breastfed for over six months (OR =1.73, CI 1.35-2.22).ConclusionsBreastfeeding is a protective factor against posterior crossbites and Class 2 malocclusion in primary and mixed dentitions, with the protective effect increasing with the months of breastfeeding. There is no clear evidence for breastfeeding proving any benefit against other malocclusion risks; open bite and non-spaced dentitions.

Interventions for caries in primary teeth; mapping reported outcomes in clinical trials over the last 30 years

Background Dental caries (tooth decay) is the most prevalent disease in school age children and carries a burden of pain and infection. Clinical trials investigating interventions (fillings and other caries management techniques) to mitigate these have no agreed core outcome set making research design difficult and complicating evidence synthesis. The first step in addressing these issues is to map the current status.

Small trial finds beneficial effect for MI Paste in preventing white spot lesions during orthodontic treatment.

Study designDouble blind randomised controlled trialInterventionSixty patients undergoing orthodontic treatment were randomised to receive either MI Paste Plus (GC America, Alsip III) or a placebo paste (Toms of Main, Salisbury, UK). To be included, the patients had to be 12 years of age or over, in the permanent dentition, and be considered to be compliant with using the paste. Patients were excluded if they; had been undergoing extensive fluoride regimes, had an impacting medical or dental condition, had been receiving fluoride treatment for white spots, be planning to move within 6 months, or have an allergy to IgE casein. The pastes were self-administered in a fluoride tray for 3 to 5 minutes each night after brushing, for a period of 3 months.Outcome measuresOutcomes were measured at baseline, then at 4, 8, and 12 weeks into treatment) using 2 measures. Standardised photographic records were used to assess WSLs using Banks and Richmonds decalcification index score, from first premolar to first premolar in the maxilla and mandible. Three operators scored the photographs independently. The International Caries Detection and Assessment System (ICDAS) was used for the labial surfaces of the teeth and the scores (0-6) for surfaces were added together to give an overall score.ResultsFive patients refused to participate before the trial began and out of the 60 patients randomised, 50 completed the study (26 MI Paste Plus group 24 in placebo group). There was a 53.5% in the enamel decalcification index score in the MI Paste Plus group but an increase of 91.1% in the placebo group at the end of the 12 week period; ICDAS scores were added together to give an overall score for all teeth; the MI Paste Plus group score was 145 at baseline and 80 after 12 weeks, a 44.8%reduction; in the placebo group, the scores were 116 and 166 respectively, an increase of 43%.ConclusionsMI Paste Plus prevented and decreased the number of WSLs during orthodontic treatment with the placebo paste group having an increase in the number of WSLs during the trial. These effects were most noticeable on the gingival surfaces. Incisal enamel decalcification index scores were consistently higher than other tooth surfaces, including gingival.

The thumb-sucking deterrent and orthodontic retainer appliance

This case report illustrates a simple and effective removable thumb-sucking deterrent appliance used to treat an 18-year-old female. The thumb-sucking deterrent appliance described is easy to fabricate, requires little adjustment chairside and could easily be used in general dental practice in motivated patients.