Patient reported experiences and treatment outcomes of orthodontic patients treated within secondary care settings in the South West of England during the COVID-19 pandemic.

OBJECTIVE: To assess the impact of the temporary cessation of orthodontic services on patients undergoing treatment during the COVID-19 pandemic. DESIGN: Two-phase multicentre service evaluation. SETTING: Secondary care orthodontic departments in the South West of England. MATERIALS AND METHODS: Phase 1 - Patient-Reported Experience Measure questionnaire (PREM). The questionnaire was distributed to patients who had undergone orthodontic treatment during the COVID-19 pandemic once services had resumed. Phase 2 - assessment of treatment outcomes, specifically with the Peer Assessment Rating (PAR) Index. A total of 280 PAR scores were obtained from a cohort of patients treated before and during the pandemic. RESULTS: A total of 711 PREM questionnaires were completed. Participants generally felt relaxed when visiting secondary care settings, orthodontic departments and whilst wearing orthodontic appliances during the pandemic. Nearly 40% of participants were concerned that the pandemic would impact on their treatment, particularly treatment length. Treatment outcomes revealed that patients treated before and during the pandemic experienced percentage PAR score reductions of 83.9% and 80.6%, respectively. Patients receiving treatment during the pandemic experienced longer treatment durations of 126 days. CONCLUSION: During the pandemic, low levels of anxiety were reported with respect to receiving orthodontic treatment in secondary care settings. Irrespective of the pandemic, a high standard of orthodontic treatment was provided. However, patient concerns regarding treatment length were justified.

Chewing gum vs. ibuprofen in the management of orthodontic pain, a multi-centre randomised controlled trial - the effect of anxiety.

OBJECTIVES: Pain is a common side effect of orthodontic treatment. An objective of this study, part of a large previously reported RCT on pain and analgesic use, was to determine the effect of anxiety on perceived pain and use of analgesia. METHODS: 1000 patients aged 11-17 years, undergoing upper and lower fixed appliance treatment in nine hospital departments were recruited into this two-arm parallel design randomised controlled trial. One arm was given sugar-free chewing gum and the other arm ibuprofen for pain relief. Neither the clinicians nor patients were blinded to assignment. In addition to recording pain experience and analgesic use for 3 days following appliance placement and first archwire change, each patient recorded their level of anxiety immediately following the fitting of the appliance and the first archwire change. RESULTS: 419 chewing gum group (84%) and 407 ibuprofen group (83%) questionnaires were returned following appliance placement, and 343 chewing gum group (70%) and 341 ibuprofen group (71%) questionnaires were returned following the first archwire change. The mean anxiety scores following fitting of the appliance and first archwire change were 2.7 (SD 2.1) and 1.6 (SD 1.8), respectively. There were weak but significant positive associations between anxiety scores and pain scores. Multi-level modelling produced a coefficient for anxiety of 0.23 (95% CI 0.17-0.28) for appliance placement, suggesting a small rise (0.23) on the 11-point pain scale for a one-point increase on the corresponding anxiety scale. Following archwire change, the corresponding coefficient was 0.32 (0.24-0.39). For ibuprofen use, again simple analyses suggested a relationship with anxiety. Multi-level logistic modelling produced an odds ratio for ibuprofen use of 1.11 (95% CI 1.07-1.15) at appliance placement and 1.21 (1.10-1.33) at the first archwire change. There was a 10-20% increase in the odds of using ibuprofen for each one-point increase on the anxiety scale. No such relationship was found between anxiety and chewing gum use. There were no adverse effects or harms reported during the trial. Approvals were granted by the Research Ethics Committee (08/H0106/139), R&D and MHRA (Eudract 2008-005522-36) and the trial was registered on the ISRCTN (79884739) and NIHR (6631) portfolios. Support was provided by the British Orthodontic Society Foundation. CONCLUSIONS: There was a weak positive correlation between anxiety reported and pain experienced following both the initial fitting of the fixed appliances and at the subsequent archwire change. Patients that were more anxious tended to take more ibuprofen for their pain relief.

Comparative assessment of chewing gum and ibuprofen in the management of orthodontic pain with fixed appliances: A pragmatic multicenter randomized controlled trial.

INTRODUCTION: The aim of this randomized trial was to investigate the effect of the use of a sugar-free chewing gum vs ibuprofen on reported pain in orthodontic patients. METHODS: This was a 2-arm parallel design randomized controlled trial in 9 sites in the southwest of England. Patients about to undergo orthodontic treatment with maxillary and mandibular fixed appliances were recruited and randomly allocated to an experimental chewing gum group or a control ibuprofen group. Eligibility criteria included patients undergoing fixed maxillary and mandibular appliance therapy, aged 11 to 17 years, and able to use ibuprofen and chewing gum. The primary outcome measure was pain experienced after appliance placement using a mean of 3 recordings on a scale of 0 to 10. Secondary outcome measures were pain experienced in the subsequent 3 days, pain after the first archwire change, ibuprofen use, and appliance breakages. Pain scores were recorded with a questionnaire and posted to a collection center by each patient. Randomization was by means of a central telephone service and comprised computer-generated random numbers used to generate a sequential allocation list, with permuted blocks of variable size (2 and 4) and stratified by center. Neither the clinicians nor the patients were blinded to the intervention. Patients in the control group were permitted to use ibuprofen only, and patients in the experimental group were allowed to use ibuprofen if they did not get sufficient analgesia from the chewing gum. Data were analyzed using the principle of intention to treat with multilevel modeling to reflect the structured nature of the data (scores within patient within site). RESULTS: One thousand patients were recruited and randomized in a ratio of 1:1 to the chewing gum and ibuprofen (control) groups. The male-to-female ratios were similar in the groups. The pain questionnaire response rates were good at approximately 84% and 83% after appliance placement (chewing gum group, 419; ibuprofen group, 407) and 70% and 71% after the first archwire change (chewing gum group, 343; ibuprofen group, 341). The primary outcomes were similar for the 2 groups: mean pain scores, 4.31 in the chewing gum group and 4.17 in the ibuprofen group; difference, 0.14 (95% CI, -0.13 to 0.41). There was a suggestion that the relative pain scores for the 2 groups changed over time, with the chewing gum group experiencing slightly more pain on the day of bond-up and less on the subsequent 3 days; however, the differences had no clinical importance. There were no significant differences for the period after archwire change. The reported use of ibuprofen was less in the chewing gum group than in the ibuprofen group; after appliance placement, the mean numbers of occasions that ibuprofen was used were 2.1 in the chewing gum group and 3.0 in the ibuprofen group (adjusted difference, -0.96 [95% CI, -0.75 to -1.17; P <0.001]); after archwire change, the figures were 0.8 and 1.5 occasions (difference, -0.65 [-0.44 to -0.86; P <0.001]). After appliance placement and the first archwire change, there was no clinically or statistically significant difference in appliance breakages between the chewing gum and ibuprofen groups after either bond-up (7% and 8.8%, respectively) or the first archwire change (4.2% and 5.5%, respectively). No adverse events were reported. CONCLUSIONS: The use of a sugar-free chewing gum may reduce the level of ibuprofen usage but has no clinically or statistically significant effect on bond failures. REGISTRATION: International Standard Randomised Controlled Trial Number (79884739) and National Institute of Health Research (6631) portfolios. FUNDING: This research was supported by an award by the British Orthodontic Society Foundation.

Using the experience-based design approach to improve orthodontic care.

The experience-based design (ebd) approach is a method of measuring patient experience, which deliberately draws out subjective, emotional and personal feelings of the patients using a service. We describe how the experience-based design approach has been used to measure the experiences of teenage patients at orthodontic consultation appointments in a district general hospital. This has allowed us to identify the points in the patient's journey where they experience most anxiety and nervousness and to target service improvements in these areas. We found the ebd approach effective in measuring patient experience in a teenage patient population. We demonstrate how the service improvements implemented have reduced negative feelings during new patient consultations.

The value of a remote orthodontic assessment for children having permanent teeth extracted under general anaesthesia.

Introduction The number of children undergoing dental extractions under general anaesthetic (GA) remains high. The newly published Royal College of Surgeons guidelines in 2023 take a less prescriptive approach on balancing and compensating extractions for first permanent molars. In an effort to maintain an effective and efficient patient care pathway, an orthodontic remote assessment triage model was developed in West Dorset for the special care dentistry and community dental service.Aims The orthodontic triage form is now used across Dorset. This service evaluation assesses whether the form is still effective despite the upscaling. Furthermore, qualitative feedback was obtained from the clinicians involved in referring and triaging.Design The sample of 352 forms consisted of children aged 16 years or younger undergoing GA for dental extractions for whom orthodontic triage had been requested between March 2019 and March 2023. The clinician feedback was collected using a questionnaire.Results This service evaluation found that 53.1% of patients had their treatment plan modified following an orthodontic assessment. Positive feedback from all clinicians involved suggests there is potential to expand this model to other services.Discussion Involving the orthodontist can address orthodontic concerns which has the potential to simplify or obviate the need for future orthodontic treatment. Remote assessment reduces the need for face-to-face appointments. The clinician perspective influences willingness to further develop and expand the current pathway.Conclusion Remote triage has proved successful in Dorset. There is potential to build an initiative between primary and secondary care in the hopes of creating a universal national proforma to increase access to orthodontic opinions for children requiring dental extractions.

Stability of box genioplasty: a retrospective study.

In box genioplasty it is possible to advance, retrude, impact, and elongate, as well as to correct asymmetry. The aim of this study was to analyse the stability of box genioplasty as part of orthognathic correction. Twenty-five consecutive patients who had gone through the multidisciplinary pathway were selected. Menton and pogonion positions on radiographs taken just prior to surgery, and actual surgical movement on three-week and 12-month postoperative cephalograms, were compared. A one-sample Wilcoxon test was applied to assess whether the distributional change in advancement and vertical measurements was equal to zero. After treatment, anteroposterior changes in pogonion and vertical changes in menton were statistically insignificant (p>0.05). Our study demonstrated statistically significant stability of menton and pogonion positions after box genioplasty when surgical movement was only in the symphysis.

An email triage model for personalising paediatric permanent tooth extractions under general anaesthesia.

It is important that dental extractions under general anaesthesia (GA) are planned appropriately to avoid a repeat GA in the future. Current guidelines recommend the input of an orthodontist when the treatment plan involves a permanent tooth extraction but the number of children undergoing GA extractions makes this challenging. A model has been developed where the records of children planned for GA extraction of permanent teeth are triaged, via secure email, by an orthodontist. The orthodontist identifies patients where modification of the extraction pattern could be beneficial to longer-term oral health. For some patients this is possible from review of the records alone, but the triage also identifies those patients with more complex occlusal problems who require a face to face orthodontic assessment. This service review found that 22% of the patients triaged had their treatment plan modified by the orthodontist. For 76% of the patients, a review of their records was sufficient before finalising the plan and only 24% needed a further face to face orthodontic assessment. This model has been successful in reducing the burden of an additional orthodontic assessment for most patients while providing personalised care.

A randomized clinical trial comparing the efficacy of ibuprofen and paracetamol in the control of orthodontic pain.

INTRODUCTION: Previous research has shown that ibuprofen provides effective relief from orthodontic pain. The aim of this study was to ascertain whether paracetamol (also known as acetaminophen) provided pain relief of equivalent or greater magnitude. METHODS: A multicenter, noninferiority, randomized clinical trial was conducted in 3 orthodontic clinics; 159 patients aged 12 to 16 years attending for routine orthodontic treatment were randomly allocated to receive either 400 mg of oral ibuprofen or 1 g of oral paracetamol an hour before and again 6 hours after separator placement. Pain scores were recorded on 7 visual analog scales (10 cm) over a week. The margin of equivalence was defined as 10 mm. RESULTS: Mean orthodontic pain from 2 hours after separation to bedtime was 8.5 mm (90% CI: lower, 3.7; upper,13.2) higher in the paracetamol group. This confidence interval lies partly outside the margin of equivalence, suggesting that paracetamol is not equivalent, and excludes the value 0, suggesting that ibuprofen is superior. From day 1 onward, there was a trend for patients who had taken ibuprofen to experience less pain at most time intervals compared with the paracetamol group. Two doses of ibuprofen, taken on the day of separator placement, were insufficient to control orthodontic pain on day 1 after placement. CONCLUSIONS: A combination of preoperative and postoperative ibuprofen is more effective than paracetamol in the control of orthodontic pain.

Potential hazards of orthodontic treatment--what your patient should know.

Orthodontic treatment carries with it the risks of tissue damage, treatment failure and an increased predisposition to dental disorders. The dentist must be aware of these risks in order to help the patient make a fully informed choice whether to proceed with orthodontic treatment. This paper outlines the potential hazards and suggests how they may be avoided or minimized.

Report of an adverse incident in a randomized clinical trial.

This is a case report of a child who experienced a possible adverse reaction to paracetamol, in a randomized clinical trial comparing paracetamol with ibuprofen for control of orthodontic pain. Through this case report we highlight the importance of formulating a protocol for management of adverse events when designing a randomized clinical trial.