Periodontal outcomes associated with impacted maxillary central incisor and canine teeth following surgical exposure and orthodontic alignment: a systematic review and meta-analysis.

BACKGROUND: Maxillary incisor and canine teeth are commonly impacted and require multidisciplinary treatment to accommodate them in the dental arch. OBJECTIVES: To assess the periodontal outcomes of impacted maxillary central incisor and canine teeth, which have been successfully aligned in the arch following surgical exposure and orthodontic traction with fixed appliance therapy. SEARCH METHODS: Systematic literature searches without restrictions were undertaken in eight databases. SELECTION CRITERIA: Studies reporting surgical interventions in combination with orthodontic traction with fixed appliance therapy to align impacted maxillary incisors or canines published up to January 2023. DATA COLLECTION: Duplicate independent study selection, data extraction, and risk of bias assessment. ANALYSIS: Random-effects meta-analyses of aggregate data. RESULTS: Twenty-three studies (21 retrospective and 2 prospective) were included in the final analysis. Three studies reported outcomes for maxillary central incisors and 20 reported outcomes for maxillary canines. For maxillary central incisors, all three studies were rated as being at moderate risk of bias. For maxillary canines, 17 studies and 1 study were rated at moderate and high risk of bias, respectively. Both prospective studies were rated at a low risk of bias. Meta-analyses comparing aligned impacted maxillary canines to their non-impacted contralateral counterparts found the former had increased Plaque Index scores (mean difference [MD] 0.19; 95% confidence interval [CI] 0.03, 0.35; P = 0.03), increased clinical attachment loss (MD 0.40 mm; 95% CI 0.17, 0.63; P = 0.01), increased pocket probing depth (MD 0.18 mm; 95% CI 0.07, 0.28; P = 0.001), increased bone loss (MD 0.51 mm; 95% CI 0.31, 0.72; P < 0.001), and reduced keratinized gingival width (MD -0.31 mm; 95% CI -0.61, -0.01; P = 0.04). CONCLUSIONS: Limited evidence suggests that surgical exposure and orthodontic alignment of impacted maxillary central incisor or canine teeth, results in modest adverse effects in the periodontium. These findings should be viewed with caution as our certainty for these outcomes is very low to low due to the bias and heterogeneity. Further well-conducted studies reporting patient centred outcomes are required. REGISTRATION: PROSPERO (CRD42020225639).

Interventions to facilitate the successful eruption of impacted maxillary incisor teeth due to the presence of a supernumerary: A systematic review and meta-analysis.

INTRODUCTION: A failure of maxillary incisor eruption is commonly attributed to the presence of a supernumerary tooth. This systematic review aimed to assess the percentage of impacted maxillary incisors that successfully erupt after surgical removal of supernumerary teeth with or without other interventions. METHODS: Systematic literature searches without restrictions were undertaken in 8 databases for studies reporting any intervention aimed at facilitating incisor eruption, including surgical removal of the supernumerary alone or in conjunction with additional interventions published up to September 2022. After duplicate study selection, data extraction, and risk of bias assessment according to the risk of bias in nonrandomized studies of interventions and Newcastle-Ottawa scale, random-effects meta-analyses of aggregate data were conducted. RESULTS: Fifteen studies (14 retrospective and 1 prospective) were included with 1058 participants (68.9% male; mean age, 9.1 years). The pooled eruption prevalence for removal of the supernumerary tooth with space creation or removal of the supernumerary tooth with orthodontic traction was significantly higher at 82.4% (95% confidence interval [CI], 65.5-93.2) and 96.9% (95% CI, 83.8-99.9) respectively, compared with removal of an associated supernumerary only (57.6%; 95% CI, 47.8-67.0). The odds of successful eruption of an impacted maxillary incisor after removal of a supernumerary were more favorable if the obstruction was removed in the deciduous dentition (odds ratio [OR], 0.42; 95% CI, 0.20-0.90; P = 0.02); if the supernumeraries were conical (OR, 2.91; 95% CI, 1.98-4.28; P <0.001); if the incisor was in the correct position (OR, 2.19; 95% CI, 1.14-4.20; P = 0.02), at the level of the gingival third (OR 0.07; 95% CI, <0.01-0.97; P = 0.04) and had incomplete root formation (OR, 9.02; 95% CI, 2.04-39.78; P = 0.004). Delaying removal of the supernumerary tooth 12 months after the expected eruption time of the maxillary incisor (OR, 0.33; 95% CI, 0.10-1.03; P = 0.05) and waiting >6 months for spontaneous eruption after removal of the obstacle (OR, 0.13; 95% CI, 0.03-0.50; P = 0.003) was associated with worse odds for eruption. CONCLUSIONS: Limited evidence indicated that the adjunctive use of orthodontic measures and removal of supernumerary teeth might be associated with greater odds of successfull impacted incisor eruption than removal of the supernumerary tooth alone. Certain characteristics related to supernumerary type and the position or developmental stage of the incisor may also influence successful eruption after removal of the supernumerary. However, these findings should be viewed with caution as our certainty is very low to low because of bias and heterogeneity. Further well-conducted and reported studies are required. The results of this systematic review have been used to inform and justify the iMAC Trial.

Study protocol for the management of impacted maxillary central incisors: a multicentre randomised clinical trial: the iMAC Trial.

BACKGROUND: Failure of eruption of the maxillary permanent incisor teeth usually presents in the mixed dentition between the ages of 7 and 9 years. Missing and unerupted maxillary incisors can be regarded as unattractive and have a potentially negative impact on facial and dental aesthetics. The presence of a supernumerary tooth (or odontoma) is commonly responsible for failed eruption or impaction of the permanent maxillary incisors. The primary objective of this trial is to investigate the success of eruption associated with maxillary incisor teeth that have failed to erupt because of a supernumerary tooth in the anterior maxilla. METHODS: This protocol describes an interventional multicentre two-arm randomised clinical trial. Participants meeting the eligibility criteria will be randomised (unrestricted equal participant allocation [1:1]) to either space creation with an orthodontic appliance, removal of the supernumerary tooth and application of direct orthodontic traction or space creation with an orthodontic appliance, removal of the supernumerary tooth and monitoring. The primary outcome of this trial is to determine the prevalence of successfully erupted maxillary central permanent incisors at 6 months following removal of the supernumerary tooth. Secondary outcome measures include (1) the effect of initial tooth position (assessed radiographically) on time taken for the tooth to erupt, (2) time taken to align the unerupted tooth to the correct occlusal position, (3) gingival aesthetics and (4) changes in the self-reported Oral Health Related-Quality of Life (OHRQoL) (pre-and post-treatment). DISCUSSION: There is a lack of high-quality robust prospective studies comparing the effectiveness of interventions to manage this condition. Furthermore, the UK national clinical guidelines have highlighted a lack of definitive treatment protocols for the management of children who present with an unerupted maxillary incisor due to the presence of a supernumerary tooth. The results of this trial will inform future treatment guidelines for the management of this condition in young children. TRIAL REGISTRATION: ISRCTN Registry ISRCTN12709966 . Registered on 16 June 2022.

Psychometric validation of a pre-existing questionnaire used to measure patient satisfaction following orthodontic treatment in a UK population.

OBJECTIVE: To determine the psychometric properties of a pre-existing orthodontic satisfaction questionnaire and to assess patient satisfaction of their orthodontic treatment. DESIGN: Psychometric assessment of a pre-existing orthodontic satisfaction questionnaire. SETTING: Two sites at King's College Hospital NHS Foundation Trust. PARTICIPANTS: Individuals aged 12-15 years who had completed fixed orthodontic treatment. METHODS: An expert panel assessed a pre-existing orthodontic treatment satisfaction questionnaire for validity and readability. As a result, revisions were made to the questionnaire and it was distributed to 103 participants aged 12-15 years, on completion of their fixed orthodontic treatment (T1). Test-retest reliability of the questionnaire was assessed through completion of a second questionnaire by 17 participants, at a two-week interval (T2). The questionnaire was assessed for reliability using item-total correlations (I-TC) and Cronbach's alpha. Factor analysis allowed exploration of the underlying factor structure of the questionnaire. Test-retest reliability was assessed using Cohen's kappa coefficient. Multiple regression analysis was used to find out the significant demographic variables that predicts the satisfaction level of treatment. RESULTS: Following validity and readability assessment by the expert panel, the questionnaire was revised. Eleven items were removed following item analysis (with I-TC ⩽ 0.3). Factor analysis was deemed uninterpretable. The overall scale demonstrated greater reliability than the underlying sub-scales. Therefore, the sub-scales were removed, resulting in one scale which assessed overall orthodontic satisfaction, comprising 37 items, with a Cronbach alpha of 0.92. The test-retest reliability of the revised 37-item scale was deemed to be poor (kappa coefficient = 0.39). Multiple regression analysis identified ethnicity as a significant predictor of orthodontic treatment satisfaction (P = 0.01). CONCLUSION: This study provides a valid measure to assess orthodontic treatment satisfaction for use in a UK population aged 12-15 years on completion of fixed orthodontic treatment.

How families prepare their children for tooth extraction under general anaesthesia: Family and clinical predictors of non-compliance with a 'serious game'.

OBJECTIVE: To explore family and clinical factors for usage of an online serious game designed to prepare children with ECC for dental treatment under general anaesthesia. DESIGN: Observational study. Secondary data of 60 children, aged 5-to-7, randomised to the intervention group in a phase-III randomised controlled trial [NIHR Portfolio 10006, ISRCTN: 18265148] testing the efficacy of the serious game http://www.scottga.org (available online). Usage was captured automatically, with each click, in real time. The total number of replays and total number of missing slides per game-run performed by the child, were recorded and used to monitor usage. Compliance outcomes were: total time running the game and number of completely missed slides. RESULTS: 57/60 played the game. Median age of parent/carer was 32. For 74% of the families, fathers resided at home and for 65% the parent/carer had A-levels-to-university education. At recruitment, 70% of the children were reported as anxious/highly-fearful and 37% as "significantly psychologically disturbed". CONCLUSIONS: Factors for non-compliance were absence of a father at home (P = 0.01) and higher child-anxiety (P = 0.01) and, to a lesser extent, a low parent/carer education level (P = 0.09). Interactive cartoons featuring dental assessment, oral health messages and modelling featured in the more popular slides.

Behavioral models for periodontal health and disease.

The oral health-related behavior of patients with periodontal disease is a critical determinant of their health. Psychological models of behavior provide a framework for the design of interventions to enhance oral health-related behavior. This article reviews published manuscripts on interventions to enhance oral health-related behavior, classifying the nature of the interventions according to current psychological models of behavior. Fifteen manuscripts reporting the findings of 14 studies were identified and reviewed. The present article concludes that, based on current evidence, the key elements of effective interventions are: goal setting, planning the behavior change, and self-monitoring.

How is adult patient adherence recorded in orthodontists' clinical notes? A mixed-method case-note study.

BACKGROUND: Patient adherence in orthodontic treatment is extremely important as it is linked with better treatment outcomes. Despite its importance, however, there is no shared definition of the concept. This makes the recording of adherence-related behaviors in patient notes difficult. The current study explored how, and to what extent adherence is recorded in adult patients' medical records by orthodontists working in a large National Health Service (NHS) London hospital. MATERIALS AND METHODS: A mixed-methods approach was used. A total of 17 clinicians with a mean age of 31 years (SD =4.87) provided N=20 case notes spanning N=324 appointments with patients they judged to be non-adherent. The notes were inspected for evidence of recording of patient adherence using adherence indicators identified in the literature. RESULTS: The term "adherence" did not feature in any notes. The quantitative analysis showed that the three most frequent adherence-related behaviors recorded in notes were "oral hygiene," "appointment attendance" and "breakages of appliances." Qualitative analysis not only confirmed these factors but also showed that 1) the clinical aspects of treatment, 2) clinician-patient interaction factors and 3) patient attitudes also featured. This part of the analysis also highlighted inconsistencies across case notes in terms of the amount of information being recorded. CONCLUSION: Adherence as a term does not feature in the clinical case notes of clinician-identified non-adherent adult patients, while predictors of adherence are recorded with varying degrees of consistency.

Social inequalities in adult oral health in 40 low- and middle-income countries.

OBJECTIVE: This study evaluated social inequalities in adult oral health across several low- and middle-income countries. METHODS: We used data from 40 countries that participated in the World Health Surveys. Participants' socio-economic position was assessed using the wealth index. Oral health was assessed using two perceived measures, namely total tooth loss and whether they had any problems with their mouth and/or teeth during the last 12 months (perceived needs). Absolute and relative wealth inequalities in oral health were measured using the slope index of inequality (SII) and the relative index of inequality (RII), respectively, after adjusting for participants' sex, age and education. RESULTS: There were wealth inequalities in total tooth loss and perceived needs in most countries. However, significant monotonic gradients were found in 21 countries for total tooth loss and in 18 countries for perceived needs. Two distinctive patterns of social inequality in oral health were found across countries using the RII and the SII. For total tooth loss, pro-rich inequality was found in 25 countries (significant RII/SII in eight countries) and pro-poor inequality was found in 15 (significant RII/SII in three countries). For perceived needs, pro-poor inequality was found in 26 countries (significant RII/SII in six countries) and pro-rich inequality was found in 14 (significant RII/SII in five countries). CONCLUSIONS: The well-documented social gradient in adult oral health favouring the rich was not present in all low- and middle-income countries. Pro-poor inequalities in total tooth loss, and particularly in perceived dental-treatment needs, were observed in some countries.

The effects of dental anxiety and irregular attendance on referral for dental treatment under sedation within the National Health Service in London.

OBJECTIVE: To investigate whether the relationship between dental anxiety and referral for treatment under sedation is explained by attendance patterns and oral health. METHODS: Structural Equation Modeling was used on the covariance matrix of the covariates to test hypothesized inter-relationships. Subsequently, we modeled the probability of referral for treatment under sedation with a multiple logistic regression taking into account inter-relationships between the independent variables. RESULTS: A direct significant association of referral with dental anxiety and attendance patterns was detected, but not with oral health status. However, oral health and anxiety were highly correlated. Also signaled were correlations between age and education and between gender and bad past experience. CONCLUSION: Referral for treatment under sedation appears to be motivated by both fear and irregular patterns of attendance. Coupled with behavioral treatments to address dental fear and attendance, sedation can be an important part of comprehensive care where curative treatments are long or unpleasant for patients.

Recovery of sensation after orthognathic treatment: patients' perspective.

INTRODUCTION: In this study, we considered patients' self-assessments to establish the recovery of sensory disturbance and the resultant distress over a 6-month postoperative recovery period after orthognathic surgery. METHODS: A prospective longitudinal cohort questionnaire survey recruited 47 consecutive patients who met the study criteria (16 years of age or over; single jaw or bimaxillary surgery). A questionnaire to measure perceived facial and oral sensory loss was sent to the participants at 1 week, 6 weeks, and 6 months postsurgery. RESULTS: Thirty-one participants (66%) completed the first questionnaire, and 26 (55%) completed all 3 assessments. The total sample comprised 14 male and 17 female subjects with a mean age of 21.2 years (SD, 4.93 years). There was a marked reduction in the proportion reporting sensory impairment at the 26-week point for both sites, although more so intraorally. At all 3 times, there were high correlations between the extent of sensory loss and the distress associated with it. CONCLUSIONS: Change in sensation occurs rapidly in the first 6 weeks postoperatively and more slowly thereafter. The distress caused by sensory loss is strongly related to the amount of sensory disturbance for both the face and the mouth.

Stress in dental specialists: a comparison of six clinical dental specialties.

OBJECTIVE: To describe and compare the levels of stress reported by dental practitioners working within clinical dental specialties. METHOD: Questionnaire survey of 220 dental practitioners identified from the General Dental Council lists of specialist practitioners in the following clinical specialties: orthodontics, paediatric dentistry, restorative dentistry, endodontics, periodontology, prosthetic dentistry. FINDINGS: The clinical specialties did not differ in their reported levels of stress. Practitioners working in the field of paediatric dentistry reported the highest median levels of reported stress for three of the four scales, though this trend was not significant. CONCLUSIONS: The practitioners surveyed from six clinical specialties did not experience significantly different sources of stress.