Comparing the Salzmann Index to automatic qualifying conditions when selecting medically necessary orthodontic patients.

INTRODUCTION: This study compared the Salzmann Index (SI) to the American Association of Orthodontists-proposed Automatic Qualifying Conditions (AQC) list in determining eligibility for medically necessary orthodontic care (MNOC). In Pennsylvania, The SI must reflect a score of ≥25, whereas the AQCs are considered binary indicators of a treatment need-the presence of any AQC qualifies a patient for treatment under Medicaid. This study was designed to determine whether the same patients are selected as eligible for MNOC regardless of which selection method is used. METHODS: The orthodontic records of 139 participants aged 10-17 years were used to calculate SI scores and identify any AQCs present. McNemar's test of agreement was used to compare patients selected for treatment needs on the basis of SI to those selected on the basis of the presence of an AQC. RESULTS: The mean SI score was 14.7. Twelve patients (8.6%) were selected for treatment needs because of an SI of ≥25, whereas 44 patients (31.7%) were deemed to have at least 1 AQC present. Of the 44 patients with AQCs, only 11 had SI scores of ≥25. McNemar's test of agreement found that SI score and AQC presence did not select patients similarly (P <0.001). CONCLUSIONS: The SI and AQCs do not appear to select the same patients for MNOC, suggesting that replacing the SI with a list of AQCs would significantly impact which patients are selected for Medicaid-funded orthodontic care in Pennsylvania.

Relationship of 3 indexes of orthodontic treatment need used by Medicaid and oral health-related quality of life.

INTRODUCTION: This study aimed to assess the relationship between 3 indexes of orthodontic treatment need that are used by Medicaid, namely the Salzmann Index (SI), the handicapping labiolingual deviation (HLD) Index, and the HLD California Modification Index, and oral health-related quality of life (OHRQOL). METHODS: The orthodontic records of 100 participants aged 11-14 years were used to calculate occlusal index scores. The condition-specific oral impacts on daily performances (OIDP) index questionnaire was used to quantify OHRQOL and to identify detriments attributable to malocclusion-related conditions (MRCs). The relationship between occlusal index scores and OHRQOL was analyzed using descriptive statistics, Spearman rank-order and biserial correlations, and logistic regression. RESULTS: The mean index scores were: SI, 15.4; HLD, 13.2; and HLD California Modification, 15.8. Ninety percent of participants did not have normative orthodontic treatment need according to current index criteria. OIDP scores were not normally distributed, and the mean score was 3.1. Of those participants who reported an impact, 83% attributed at least 1 of those impacts to MRCs; however, 90% of these were of mild or moderate intensity. Smiling was the performance most impacted by MRCs. The only statistically significant correlation between an occlusal index and OIDP scores was for the SI, though this association was weak (r = 0.27). None of the variables used in the logistic regression model (age, sex, 3 index scores) were significant predictors of OHRQOL. CONCLUSIONS: No meaningful association exists between the 3 indexes studied and OHRQOL. These findings challenge the validity of current systems for the allocation of Medicaid-funded orthodontic treatment.

Influence of maxillary lateral incisor width ratio on perception of smile esthetics among orthodontists and laypersons.

OBJECTIVE: This study aimed to analyze the impact of different maxillary lateral incisor width ratios on the perception of smile esthetics among orthodontists and laypersons. METHODS: A smile photograph of a male subject showing the lips and gingival margins was selected. The smile was standardized for maxillary central incisor width proportions and ideally perceived smile esthetics. The maxillary lateral incisor width was symmetrically modified in increments of ratios of the central incisor from a ratio of 4:10 to a ratio of 8:10. The images were analyzed by 283 laypersons and 83 orthodontists who ranked the level of attractiveness using a visual analog scale. RESULTS: There were significant differences between the esthetic perception of the five different width ratios, and between the orthodontists and laypersons in their evaluations of esthetics (P < 0.0004). There were no significant differences in esthetic evaluations between genders. CONCLUSIONS: For orthodontists, the most attractive width ratio was 5.7:10, while the highest ranked ratio among laypersons was 8:10, although laypersons ranked all ratios very similarly. Both groups ranked the width ratio of 4:10 the lowest. Orthodontists were more critical in their assessment of esthetics. CLINICAL SIGNIFICANCE: To what proportions or protocol should a peg-shaped maxillary lateral incisor or missing lateral, that is, to be replaced with an implant/crown be restored? This is an important clinical question that is often encountered by the orthodontist and the restoring dentist. The literature suggests that orthodontists and laypeople have different perceptions of smile esthetics, and it is important to have patient centered goals when treatment planning. Further research is necessary to identify the width ratio of which the lateral incisor is perceived to be esthetic as well as the ideal ratio to consider when restoring lateral incisors. This research assessed and compared the perception that orthodontists and laypeople have on smile esthetics regarding different width ratios of lateral incisors.

The Salzmann Index and discrepancy index correlation: Determining a threshold discrepancy index score for Medicaid approval.

INTRODUCTION: This study aimed to compare patients' Salzmann Index scores for those who applied for Medicaid orthodontic coverage in Pennsylvania with their corresponding American Board of Orthodontics discrepancy index (DI) scores to assess if there is a correlation between Salzmann and DI scores. In addition, a threshold DI score was calculated that would correspond to Medicaid coverage approval. The study intended to answer the following questions: is there a correlation of 0.7 or greater between a patient's Salzmann Index and their DI? If so, is there a particular DI score that can be used as the minimum score for approving Medicaid orthodontic coverage in the state of Pennsylvania? METHODS: Salzmann Index scores, DI scores, and approval and disapproval results for Medicaid orthodontic coverage were obtained from 104 subjects aged between 10 and 17 years. A linear regression model was generated to assess if there was a correlation between the Salzmann scores and DI scores. If a correlation coefficient of 0.7 or greater were found, a threshold Salzmann Index score would be determined for subjects who were approved for Medicaid orthodontic coverage. The threshold Salzmann score would be used in the linear regression formula to find the corresponding DI score, which would be designated as the threshold DI score for approval for Medicaid orthodontic coverage in the state of Pennsylvania. RESULTS: A Pearson correlation of 0.453 was calculated between the 104 Salzmann scores and DI scores, demonstrating a moderate correlation. With the correlation coefficient being lower than 0.7, binary logistic regressions were calculated to assess the predictability between a given Salzmann score and approval and disapproval for Medicaid orthodontic coverage. The Salzmann score had an overall 68.3% success in predicting Medicaid orthodontic coverage approval/disapproval. Of the 58 subjects that were approved for Medicaid orthodontic coverage, 46.6% had Salzmann scores equal to or greater than 25. Of the 46 subjects that were disapproved for Medicaid orthodontic coverage, 78.3% had Salzmann scores equal to or less than 24. CONCLUSIONS: With the lack of high prediction rates seen from the results of the regression models, the current system of Medicaid does not appear to show consistency for assessing the need for orthodontic treatment coverage. Multiple insurance companies that participate under Medicaid require a Salzmann score of 25 or greater for approval; however, the results show the Salzmann score is arbitrary in terms of approval and disapproval. There appear to be underlying factors apart from the Salzmann score that the Pennsylvania Medicaid system uses to justify whether a patient was approved or denied for coverage.

Influence of upper lip curvature on smile attractiveness in patients with different degrees of gingival smiles: A cross-sectional study with opinions from oral health providers and laypersons.

INTRODUCTION: Although there is relative consensus about approaches to gingival smile management, there are still discrepancies as to whether a gingival smile is attractive or not. The purpose of this study was to quantify the influence of upper lip curvature shape and the amount of gingival display on the perception of smile attractiveness assessed by Peruvian orthodontists, dentists, and laypersons. METHODS: A frontal photograph was digitally altered to generate 3 types of upper lip curvature shapes (upward, straight, and downward) with 5 different levels of gingival smile exposure (0 mm, 2 mm, 3 mm, 4 mm, and 5 mm). Fifteen images were generated. Three groups of evaluators (50 dentists, 50 orthodontists, and 50 laypersons) assessed the images using a visual analog scale. One-way analysis of variance with Bonferroni post-hoc tests and multiple linear regressions were applied. RESULTS: The downward lip curvature shape had a negative effect on the esthetic evaluation of the smile with gingival exposures of 3 mm or more for all the evaluating groups (approximately 20-30 points less than upward or straight smile curvature shapes, P <0.05). Laypeople gave higher scores of almost 10 points more than dentists and orthodontists when evaluating the upward lip curvature shape with 5 mm of gingival exposure during smile (P = 0.029). CONCLUSIONS: We found that upward or straight upper lip curvature shapes have a positive impact on perceived smile esthetics. In contrast, downward upper lip curvature shapes have a negative effect on perception when evaluating different degrees of gingival smiles.

Self-reported pain after orthodontic treatments: a randomized controlled study on the effects of two follow-up procedures.

OBJECTIVES: To assess the effects of a follow-up text message and a telephone call after bonding on participants' self-reported level of pain. MATERIALS AND METHODS: Eighty-four participants were randomly assigned to one of three trial arms. Randomization was performed by the Department of Epidemiology and Biostatistics of IRCCS G.Gaslini. Participants were enrolled from patients with a permanent dentition who were beginning fixed no extraction treatment at the Orthodontic Department, Gaslini Hospital. Participants completed baseline questionnaires to assess their levels of pain prior to treatment. After the initial appointment, participants were completed a pain questionnaire at the same time, daily, for 7 days. The first group, served as control, did not receive any post-procedure communication; the second group received a structured text message; and the third group received a structured telephone call. Participants were blinded to group assignment. LIMITATIONS: A larger sample size should have been considered in order to increase the ability to generalize this study's results. RESULTS: Participants in both the telephone call group and the text message group reported lower level of pain than participants in the control group with a larger and more consistent effect for the telephone call group. Most participants reported a higher level of pain during the first 48 hours post-bonding. The analgesic's consumption significantly correlated with the level of pain during the previous 24 hours. Female participants appeared to be more sensitive to pain than male participants. CONCLUSIONS: A telephone follow-up after orthodontic treatment may be an effective procedure to reduce participants' level of pain. PROTOCOL: The research protocol was approved by the Italian Comitato Etico Regionale della Liguria-sezione 3^ c/o IRCCS- Istituto G.Gaslini 845/2014. REGISTRATION: 182 Reg 2014, 16/09/2014 Comitato Etico Regione Liguria, Sez.3.

Perceptions of midline deviations among different facial types.

INTRODUCTION: The correction of a deviated midline can involve complicated mechanics and a protracted treatment. The threshold below which midline deviations are considered acceptable might depend on multiple factors. The objective of this study was to evaluate the effect of facial type on laypersons' perceptions of various degrees of midline deviation. METHODS: Smiling photographs of male and female subjects were altered to create 3 facial type variations (euryprosopic, mesoprosopic, and leptoprosopic) and deviations in the midline ranging from 0.0 to 4.0 mm. Evaluators rated the overall attractiveness and acceptability of each photograph. RESULTS: Data were collected from 160 raters. The overall threshold for the acceptability of a midline deviation was 2.92 ± 1.10 mm, with the threshold for the male subject significantly lower than that for the female subject. The euryprosopic facial type showed no decrease in mean attractiveness until the deviations were 2 mm or more. All other facial types were rated as decreasingly attractive from 1 mm onward. Among all facial types, the attractiveness of the male subject was only affected at deviations of 2 mm or greater; for the female subject, the attractiveness scores were significantly decreased at 1 mm. The mesoprosopic facial type was most attractive for the male subject but was the least attractive for the female subject. CONCLUSIONS: Facial type and sex may affect the thresholds at which a midline deviation is detected and above which a midline deviation is considered unacceptable. Both the euryprosopic facial type and male sex were associated with higher levels of attractiveness at relatively small levels of deviations.

Practitioner and patient perceptions of orthodontic treatment: is the patient always right?

PURPOSE: As dentists embrace evidence-based clinical practice, we place increased emphasis on patient values. Standards like Angle Classification are not related to patient perceptions of the tangible benefits of treatment. This study quantifies the differences dentists and patients perceive in orthodontic treatment outcome. MATERIALS AND METHODS: A survey is used to quantify a patient's perception of orthodontic treatment. It was completed by 30 patients who completed treatment at the University of Pittsburgh School of Dental Medicine. Their responses were compared with the perceptions of five orthodontists, three general dentists, and two prosthodontists. RESULTS: Multivariate analysis of variance found the differences between and within the subjects to be significant at p < 0.004. Univariate analysis of variance of the initial scores showed the data to be significant at p < 0.002 and pairwise comparisons showed significant mean differences. Final score analysis of variance was significant at p < 0.001 and pairwise comparison showed significant mean differences. CONCLUSIONS: Patients and general dentists have a significantly less favorable initial perception of their dental esthetics and function when compared with orthodontists. Final scores of esthetic and functional perceptions between the patients and all three dentist groups showed significant differences, with patients perceiving the results of their treatment more favorably than practitioners. CLINICAL SIGNIFICANCE: The data herein elucidates differences in the value systems of professionals and patients. It is meant to encourage dentists to consider whether these differences justify the persistence of traditional orthodontic treatment goals or if treatment planning should incorporate consideration of each individual patient's preferences to maximize utility.

The effects of a vibrational appliance on tooth movement and patient discomfort: a prospective randomised clinical trial.

INTRODUCTION: The aim of this study was to assess the rate of tooth movement and discomfort experienced by orthodontic patients using a vibrational appliance (Tooth Masseuse). METHODS: In this randomised controlled trial (RCT), 66 consecutive patients were assigned to a control or experimental group. The experimental group was instructed to use a vibrational appliance for a minimum of 20 minutes per day. All of the patients had the same fixed appliance and a 0.014 inch thermal NiTi wire during the 10 week study period. Impressions of the mandibular six anterior teeth were taken at 4 time points: at the start of treatment, 5 weeks, 8 weeks, and at 10 weeks after commencement. Little's Irregularity Index was used to record alignment and assess the rate of tooth movement. A discomfort score chart was used to evaluate patient pain levels at 5 time points. RESULTS: The experimental group showed a 65% reduction in irregularity at 10 weeks, while the control group showed a 69% reduction in irregularity over the same period. No significant differences in irregularity or pain levels were observed at any of the time points between the groups. CONCLUSIONS: The results demonstrate that, for 20 minute use per day, there appears to be no clinical advantage in using the vibrational appliance for the early resolution of crowding or the alleviation of pain during initial alignment.

In-vitro evaluation of frictional resistance with 5 ligation methods and Gianelly-type working wires.

INTRODUCTION: Numerous in-vitro studies have been conducted with various archwire-ligation combinations to evaluate the effect of wire size and ligation method on frictional resistance. The aim of this in-vitro study was to compare the frictional resistance during sliding mechanics with Gianelly-type stainless steel working wires, Leone slide ligature, conventional elastic ligature, and stainless steel (SS) ligature, and a conventional bracket and active and passive self-ligating brackets. METHODS: Three ligation methods with Victory (V) brackets--Leone (VLeone), conventional (regular) elastic (VReg), and SS (VSS)--were used with standard SS brackets, and 2 self-ligating brackets--Damon MX (Ormco/"A", St. Paul, Minn) (DMX) and In-Ovation R (GAC Intl., Bohemia, NY)--were used with 2 rectangular SS wires (0.016 x 0.022 and 0.018 x 0.022 in). Therefore, 5 ligation methods and 2 wire sizes were evaluated with respect to their effects on frictional resistance. RESULTS: No statistically significant differences were found between the SS ligation method and DMX (neither produced measurable static friction). For the wire size 0.016 x 0.022-in SS, the DMX and SS produced significantly less static friction than the In-Ovation R, VLeone, and VReg. The In-Ovation R produced significantly less friction than both the VLeone and VReg, whereas the VLeone produced significantly less friction than the VReg. For the wire size 0.018 x 0.022-in SS, the overall results were the same, except that the In-Ovation R produced significantly more friction than the VLeone. An increase in wire size (from 0.016 x 0.022 to 0.018 x 0.022 in) led to an increase in friction in all bracket-archwire combinations (except DMX and VSS, which showed no measurable friction at either wire size). CONCLUSIONS: The Leone slide ligature showed less friction at both wire sizes than VReg; however, it showed significantly more friction than both DMX and VSS. DMX and VSS brackets produced no measurable friction with either 0.016 x 0.022-in or 0.018 x 0.022-in wires. An increase in wire size (from 0.016 x 0.022 to 0.018 x 0.022 in) led to an increase in friction in all bracket-archwire combinations (excluding DMX and VSS, which showed no measurable friction at either wire size).

Comparing the plaque-removal ability of a triple-headed toothbrush versus a conventional manual toothbrush in adolescents with fixed orthodontic appliances: A single-center, randomized controlled clinical trial.

OBJECTIVE: The objective of this trial was to compare the plaque removal ability of a triple-headed toothbrush to a conventional manual toothbrush in adolescents with fixed orthodontic appliances. MATERIALS AND METHODS: Sixty adolescent patients undergoing orthodontic treatment were randomly assigned to brush one time with either a conventional manual toothbrush or a triple-headed toothbrush. The main outcome was the post-brushing plaque index as measured by the Silness-Löe plaque index. RESULTS: Sixty patients (mean age, 14.2; standard deviation, 1.65) were randomized in a 1:1 ratio to either a manual toothbrush group or a triple-headed toothbrush group. Baseline characteristics were similar between the two groups. There were no dropouts. The mean post-brushing plaque index was 0.84 (95% CI, 0.67-1.02; SD, 0.60) for the conventional manual toothbrush group, and 0.31 (95% CI, 0.13-0.49; SD, 0.48) for the triple-headed toothbrush group. There was a statistically significant difference in the mean plaque index of 0.53 (95% CI, 0.28-0.78; P<0.001) between the two groups after brushing. No harms were observed. CONCLUSION: The results of this study indicate strong evidence that the triple-headed toothbrush leads to a significantly lower plaque index compared to the conventional manual toothbrush post-brushing.

Long-term dental and skeletal effects of mandibular advancement devices in adults with obstructive sleep apnoea: A systematic review.

OBJECTIVE: This systematic review aimed to clarify whether there are any significant long-term sequelae to wearing mandibular advancement devices focusing on dental and skeletal effects in adults with OSA. MATERIALS AND METHODS: Databases, including PubMed, Medline, Embase, Web of Science, Cochrane Central Register of Controlled Trials, and SAGE Journals. Hand searches and grey literature were also used. A piloted data collection form was used to extract the appropriate data. RESULTS: Twenty-three reports of 19 studies were included. Five had serious risk of bias while 18 had moderate risk of bias. Meta-analysis revealed a significant change in overbite and overjet. I-squared analysis showed a high level of statistical heterogeneity. A moderate correlation was found between wear time and amount of change. CONCLUSION: Mandibular advancement devices will cause a small but statistically significant change in the dentition of long-term wearers. Skeletal changes are generally secondary to dental changes.

Deconstructing evidence in orthodontics: making sense of systematic reviews, randomized clinical trials, and meta-analyses.

Much has been written in support of systematic reviews and the randomized clinical trials and meta-analyses upon which they are based. Clearly, the medical profession (as opposed to the dental profession) has been the leader in publishing the benefits of systematic reviews over the traditional, qualitative narrative reviews. At the same time, the medical profession also appears to be ahead of the dental profession in recognizing the limitations of such reviews. That said, there are a number of inherent problems with systematic reviews, as well as the randomized clinical trials and meta-analyses that back them up. To better facilitate evidence-based decision making, this article discusses the shortcomings of systematic reviews so that practitioners are fully aware of their drawbacks, as well as their benefits.

Self-ligating brackets: present and future.

Recently, there has been a resurgence in the use of self-ligating (SL) brackets, which were introduced in the early 20th century. From a synthesis of both in-vitro and in-vivo evidence-based literature, we present general concepts, principles, and axioms. The references to "active" and "passive" SL brackets are explained and juxtaposed in relation to their perceived advantages and disadvantages. We also present new concepts in regard to the future of SL brackets: combination bracket system, hybrid system, and selective use of SL brackets.