Introduction

This is a really interesting paper produced by a well-established international team of researchers based in Dublin, Bern and Riyadh, investigating an issue of fundamental importance to the practice of evidence-based orthodontics. The novelty, importance and quality of this study are reflected in its publication in the Journal of Dental Research, a high-impact journal that is very difficult to publish in.

Predatory journals

Predatory academic journals are a product of the online publishing industry and purport to be legitimate, adhering to high standards of publishing ethics and facilitating rapid open-access publication, but often they do not. Many of these journals aggressively solicit submissions, charge high publication fees, and rely on high-volume, rapid publication output for their financial model. For these reasons, the peer review and editorial processes are often less than robust, leading to the publication of papers of low methodological quality.

Predatory Publications Bias the Findings of Orthodontic Meta-analyses

M P Maroulakos, Z Tatas D Al-Moghrabi, N Pandis, P S Fleming

Journal of Dental Research

DOI: 10.1177/00220345261466209

What did they ask?

They did this study to ask;

“What is the prevalence of predatory papers included in meta-analyses of orthodontic systematic reviews and to describe the prevalence and the characteristics of recent systematic reviews published in legitimate, suspect, or predatory journals within the field of orthodontics”.

What did they do?

This study has investigated the influence of predatory publishing in orthodontics, focusing specifically on orthodontic systematic reviews, which represent a fundamental component of evidence-based practice. The authors searched various databases for English-language orthodontic systematic reviews published between 2020 and 2023, and then analysed these reviews for a number of parameters, including their general characteristics (type, topic, authors), the type of journal in which they were published, and, importantly, whether the journal was regarded as legitimate, suspect, or predatory.

They further investigated one meta-analysis from each of these systematic reviews and extracted data on the primary studies included in each (again, assessing whether any had been published in predatory or suspect journals). Specifically, any meta-analyses containing at least one study published in a suspect or predatory journal underwent a further subset analysis (effect measure, sample size, heterogeneity), including analyses of the data using either all studies or only those published in legitimate journals.

What did they find?

There were some really interesting findings, albeit slightly depressing. They identified 340 eligible systematic reviews, and among these, 114 (33%) contained primary data from at least one predatory or suspect journal. The majority of these systematic reviews (60%) were published in broader-scope medical and general science journals, not orthodontic – and 16% of these journals were classified as predatory or suspect. Among the 114 systematic reviews that had their primary meta-analyses re-analysed, the median sample size within the included studies was only n=20, with a median I2 score of 85% (demonstrating that studies with small sample sizes and substantial heterogeneity often populate these meta-analyses). Recalculation using all included studies, or only those published in legitimate journals, resulted in pooled estimates decreasing in 55% of meta-analyses and increasing in 45%.

What did I think?

The importance of this study is that it provides data supporting the perception many of us who spend time reading these systematic reviews have held for years – that they often include primary studies of questionable validity and probably should not have been published. Perhaps most surprising is the sheer scale of data that is out there, emanating from predatory or suspect journals. One in three orthodontic meta-analyses contains primary data from these journals, and almost one in six orthodontic systematic reviews. The effect of data derived from predatory publishing on pooled estimates in meta-analyses is unpredictable and therefore adds considerable uncertainty to the evidence.

The harsh reality is that the current orthodontic evidence base, derived from systematic reviews, is likely to be significantly distorted by predatory publishing practices, with over- and under-estimation of treatment effects commonplace. There are too many journals, too many systematic reviews, and too many unreliable studies. Read them and interpret them with caution…………………..

      

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A team from Aarhus and Copenhagen did this study. Orthodontics and Craniofacial Research published the paper. 

Patient Harm From Orthodontic Care (Part I): Types and Frequency of Patient-Reported Harms From a National Database

Nikolaos Ferlias et al

Orthodontics and Craniofacial research. Advance access: https://doi.org/10.1111/ocr.70168

This paper is open access so we can all read it. 

What did they ask? 

They did this study 

“To analyse the reasons why patients file claims for compensation related to orthodontic care, to summarise the events that led to patient harm and to describe the types of harms associated with the provision of orthodontic care”. 

What did they do? 

They conducted a retrospective evaluation of data from the Danish Dental Compensation Association Database. This is a national no-fault compensation scheme. Patients who experience physical or medical injury in connection to dental treatment can apply for financial compensation under this scheme. 

Importantly, the scheme does not provide compensation for dissatisfaction with treatment outcome.

If a patient wants to make a claim, they complete a brief online form, which is submitted to expert examiners who review the case and determine whether harm has occurred. The case is then passed on to a legal officer who makes a final compensation decision. 

The investigators analysed data from patient-reported claims related to orthodontics between June 2017 and August 2024. 

They carried out a descriptive analysis to summarise the data. 

What did they find? 

The database recorded a total of 644 patient-reported claims. When they analysed these claims, 196 (30.4%) were recognised as treatment-related harms and eligible for compensation. 

When they examined patient claims that were both accepted and not accepted, they found that relapse after treatment was the most frequent reason for a claim (18.63%), followed by lack of treatment effect (12.58%) and worsening of the occlusion (8.54%).

They then identified the causes of the harms. These were the treatment itself (51.5%), delayed diagnosis (24.5%) and problems with retention (9.2%).

When they looked at the categories of harm from orthodontic care that were accepted for compensation, they found that the most frequently recognised harm categories were

– Apical root resorption resulting in tooth loss (14.8%)

– Gingival or soft tissue injury (13.3%)

– Worsening of the occlusion after orthodontic treatment (9.2%)

The overall conclusions were 

“Most of the harms arise in the active phase of orthodontic treatment and are frequently the result of root resorption, soft tissue damage, and worsening of the occlusion after treatment”. 

What did I think? 

This is an unusual study unique to Denmark because of its complaints system. I feel that this is an interesting development because it may remove the adversarial nature of claims. Importantly, claims are handled centrally, and both the claimant and the orthodontist/dentist can appeal the decision.

I could not determine liability for the compensation awarded. This information would have been useful.

Interestingly, the compensation claim did not necessarily indicate malpractice by the provider. I know this is certainly not the case in some countries. 

When I looked at the recorded harms, it was interesting that the most common were root resorption, gingival injury, or worsening occlusion. In some ways, this may not be surprising. However, it was notable that complaints of root resorption were upheld. I had thought that our formal consent procedures, which were very specific about root resorption, would negate such claims. Again, I am not sure whether this would be the case in other countries. 

The authors highlighted some weaknesses in this study and noted that the findings were only relevant to Denmark. Importantly, the database may not capture all claims made during that period, as some would not be submitted through the database. Thirdly, it wasn’t possible to distinguish specialists from generalists. This would certainly be very important information. 

Overall, I thought this paper provided robust and highly relevant information for our consent process and clinical practice. If I were still working clinically, I would make sure to emphasise the risks they recorded in our consent process. 

       

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• Unfortunately…root resorption is, to some extent , a ... by Danny Radnzic
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This group of problems is called sleep-disordered breathing. It ranges from simple snoring to obstructive sleep apnoea, where the airway partly or fully closes during sleep. When this happens, a child may wake briefly many times without knowing it. Their sleep is broken, even if they stay in bed all night.

Why does it matter?

Good sleep is not just about feeling rested. It helps children learn, grow, manage emotions and stay healthy.

Children with more serious sleep-breathing problems may be tired or irritable during the day. They may struggle to focus at school or show changes in behaviour. In severe cases, low oxygen levels and disturbed sleep can also affect the heart and lungs.

Not every child who snores has a serious problem. But loud, regular snoring—especially with pauses, gasping, restless sleep or daytime tiredness—should not be ignored.

What causes it?

A common cause is enlarged tonsils and adenoids. These are small areas of tissue at the back of the throat and nose. If they become too large, they can narrow the airway while a child sleeps.

Weight can also play a part for some children. Other children may have health conditions that make sleep breathing problems more likely.

Who should diagnose it?

This is an important point: dentists and orthodontists may notice signs that raise concern, but they should not diagnose sleep-disordered breathing on their own.

A proper assessment should be carried out by a medical professional with experience in children’s breathing and sleep, such as an ear, nose and throat specialist or a paediatric respiratory doctor. They will ask about sleep, breathing and daytime symptoms. Sometimes they may use overnight monitoring or a sleep study.

Can orthodontics cure it?

It is tempting to think that changing the shape of the teeth or jaws will solve a breathing problem. However, the evidence does not support treating orthodontics as a simple cure for childhood sleep-disordered breathing.

If enlarged tonsils and adenoids are blocking the airway, medical treatment is usually the main answer. In some children, removing these tissues can greatly improve breathing and sleep. Other treatments may include support with weight management or breathing support during sleep.

Orthodontic treatment may have a role in carefully selected cases as part of a wider medical plan. But it should not replace a proper diagnosis or evidence-based medical care.

The key message

Snoring can be a warning sign, but it is not a diagnosis. If a child snores regularly, has pauses in breathing, gasps during sleep, sleeps restlessly, or is unusually tired or unfocused during the day, parents should speak to their GP or paediatric healthcare team.

The goal is simple: help children breathe well, sleep well and feel well—using the right treatment for the real cause of the problem.

This post is based on Kevin O’Brien’s discussion of childhood sleep-disordered breathing and orthodontic treatment. It is for general information and is not medical advice.

Based on the linked article, which stresses that childhood sleep breathing problems need medical assessment and that orthodontics should not be presented as a stand-alone cure. Source article

      

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This system was examined in this study. 

A team from Sydney, Australia, did the study. The European Journal of Orthodontics published the paper.

The use of teleorthodontics and artificial intelligence for orthodontic triage and screening in a publicly funded healthcare system: A crossover randomised controlled trial

Maxim Milosovic et al.

EJO Online: https://doi.org/10.1093/ejo/cjag050

What did they ask? 

They did this study too. 

“Compare the validity of a novel tele-orthodontics and artificial intelligence (AI) triaging method using dental monitoring with gold standard face-to-face consultation, using the index of orthodontic treatment need (dental health component) at a treatment threshold of 3.” 

What did they do? 

They conductedid a prospective single-centre 2-by-2 crossover randomised controlled trial. 

Participants 

Inclusion criteria were: 

Patients on the New South Wales waiting list aged more than 5 years who had been referred by dentists for orthodontic triage. They had access to a smartphone and email address

Intervention. 

TAI First.

They provided participants in the study with a Dental Monitoring Scan Box Pro and written instructions. The participants then submitted two scans of sufficient quality for the dental monitoring algorithm to accept them. They also completed a history form that included questions about traumatic deep bite and any speech and masticatory issues. 

Then one of the two investigators, who were senior orthodontic residents trained in the use of IOTN, assigned the IOTN dental health component grade. 

Control 

This group was examined face-to-face first. This involved the clinical examination of the patients and a patient-based medical history form. This enabled allocation of the IOTN grade. 

After a two-month gap, the same patients were screened again using the method not used in their first examination. 

Outcomes 

The primary outcome was the validity of the TAI triage in accepting or rejecting referrals, based on a minimum IOTN DHC threshold of IOTN ≥ 3. The study team also examined referral acceptance thresholds of IOTN ≥ 4 (this is the cut-off point for treatment in the UK).

They conducted a clear sample size calculation, which showed that they needed to enrol 136 participants in the study. 

They randomised participants to the test or control allocation using a permuted randomised block design. This was done by administrative staff, who allocated participants via telephone. 

It was not possible to blind the investigators and participants to the allocation sequence; however, the investigators were blinded to all other outcomes.

Standard exploratory statistics were carried out. The diagnostic validity of the triage for IOTN was evaluated by calculating the sensitivity, specificity, positive predictive value, and negative predictive value of the test. 

What did they find? 

At the end of the study, 178 participants completed the investigation. There were no differences between the two groups at the start of the study. 

They provided a reasonable amount of data on the effectiveness of the screening; however, willam onlo look closely at the screening at the IOTN thresholds of 3 and 4. At the IOTN ≥ 3 threshold, the TAI triage has a sensitivity of 1 and a specificity of 0.67 when compared with face-to-face consultations. At the IOTN ≥ 4 threshold, the sensitivity was 0.93, and the specificity was 0.73. 

Sensitivity and specificity are measures used to evaluate a diagnostic test against a gold standard. Sensitivity is the true-positive rate: the proportion of people with the disease who are correctly identified by the test. Specificity is the true-negative rate: the proportion of people without the disease who are correctly identified by the test. Ideally, both sensitivity and specificity equal 1.

The figures from this study show that the sensitivity and specificity at both IOTN levels examined were satisfactory for most screenings. Importantly, the sensitivity values were high. 

The authors also found that screening duration is shorter with TAI than with face-to-face consultation, although I could not find any data on this. 

Their overall conclusion was;

“Triage was a valid and reliable tool for screening orthodontic patients in a public system. It effectively categorised patients with malocclusions ranging from severe to mild based on malocclusion severity and IOTN. However, they emphasised the need for careful classification of borderline malocclusions due to the limitations of certain assessment traits”. 

What did I think? 

I have done a fair amount of research on referral patterns, screening, and the use of IOTN in a public health service. As a result, I found this paper very interesting and highly relevant. 

Overall, their methodology was sound, and the study was well conducted and clearly written up. 

When I reviewed other studies examining the same question in orthodontic screening, I was particularly interested in the effectiveness of the TAI method. This suggests that, with further development to enhance measurement accuracy and to identify other features such as crossbites, AI has a potential role in orthodontic screening. 

This would be a highly useful development in countries where orthodontic treatment is provided by a national health service following a screening programme. 

This is another example of the exciting world of artificial intelligence that we are entering. The pace of change is remarkable, and studies like this are vital to our understanding of this new technology. 

       

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A new study looked at whether orthodontic expansion could help.

Orthodontic expansion is a treatment that makes the upper jaw wider. It is often used when the upper jaw is too narrow or when the back teeth do not fit together well. In this study, the researchers wanted to know if expansion could also improve breathing during sleep.

What did the researchers do?

The study included 45 orthodontic patients aged 14 to 17. All had a narrow upper jaw and breathed through their mouths. They were past the main stage of puberty, so jaw growth was less likely to explain any changes.

They placed the teenagers at random into one of three treatment groups. Each group used a different type of rapid palatal expander. One type used small screws in the roof of the mouth. This type is called MARPE.

The researchers checked the teenagers before treatment and again about three months later. They measured breathing during sleep, airflow through the nose, tooth and jaw changes, and daytime sleepiness.

They also compared the results with a group of healthy teenagers who did not have treatment.

What did they find?

The main result was encouraging. After expansion, the treatment groups had fewer breathing pauses or restrictions during sleep. They also had fewer drops in blood oxygen.

One measure used in the study was the apnoea-hypopnoea index, or AHI. This counts breathing events during sleep. A lower number is better. In all three treatment groups, the AHI fell after expansion.

The MARPE group showed the biggest improvement. This may suggest that expansion supported by small screws can be useful for some older teenagers.

However, the teenagers did not report clear changes in daytime sleepiness. Their scores were in the normal range before and after treatment. This is important because better test results do not always mean a person feels very different.

What should we make of this?

This was a well-planned randomised trial, which makes it more useful than studies that only look back at old patient records. Still, it was a small study and the follow-up was short.

The sleep test used was practical, but it was not the most detailed test available. A full overnight sleep study is usually seen as the best way to assess sleep apnoea.

The findings do not mean that orthodontic expansion is a cure for every teenager who snores or has sleep apnoea. Sleep problems can have many causes. Weight, nose and throat health, hormones, and the shape of the airway can all play a part.

But the study gives us a helpful clue: for teenagers with a narrow upper jaw, expansion may improve some measures of sleep breathing. More large studies, with longer follow-up, are still needed.

If you are worried about snoring, pauses in breathing, or poor sleep, speak to a parent, dentist, orthodontist, or doctor. Good sleep is too important to ignore.

Adapted from Kevin O’Brien’s discussion of the trial, “New evidence from a trial of Orthodontic Expansion and Sleep Apnoea in Teenagers.”

      

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It can range from regular loud snoring to a more serious condition called obstructive sleep apnoea. In sleep apnoea, breathing can stop and start many times during the night.

A group of orthodontic experts in America has updated its advice about this topic. Their main message is simple: breathing problems during sleep need to be checked by the right medical professional.

What can an orthodontist do?

An orthodontist is a dentist who helps guide how teeth and jaws develop. They might notice clues that a child could have sleep-breathing problems, such as questions about snoring or feeling very tired in the daytime.

But an orthodontist cannot diagnose sleep apnoea just by looking at someone’s teeth, jaw, or an X-ray. If they are worried, they can help by suggesting that the child and their family speak to a doctor or sleep specialist.

The best test for finding obstructive sleep apnoea is usually an overnight sleep study. It measures what happens while someone is asleep.

Can braces stop sleep problems?

Not necessarily. The experts found no good evidence that orthodontic treatment can prevent sleep-disordered breathing from happening in the future.

That means braces, expanders, or special jaw appliances should not be sold as a guaranteed way to prevent snoring or sleep apnoea. Some of these treatments may still be useful for a person’s teeth or bite, but they should only be considered as part of a proper plan after a medical diagnosis.

For example, widening the upper jaw with an expander may be right for someone who needs it for orthodontic reasons and also has a confirmed sleep problem. But it is not a magic “sleep cure” for everyone.

What about tongue ties and tooth removal?

The updated advice says there is no evidence that tongue ties cause obstructive sleep apnoea. So cutting a tongue tie as a routine treatment for sleep-breathing problems is not supported by the evidence.

The experts also found no evidence that taking out teeth for orthodontic treatment causes sleep-disordered breathing. Moving teeth backwards does not automatically make someone’s airway too small either.

The important takeaway

Sleep-breathing problems are complicated. They can have many different causes, and different children may need different help.

The best care happens when health professionals work together. Doctors, sleep specialists, dentists, orthodontists, and families can all have a part to play.

If you or someone you know snores loudly, seems to stop breathing during sleep, wakes up often, or is always exhausted in the daytime, tell a parent or trusted adult. The next step is to talk with a doctor—not to jump straight to a dental treatment.

This post is based on Kevin O’Brien’s summary of the American Association of Orthodontists’ updated recommendations.

      

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I have based this on feedback from questions posed at lectures, discussions on social media, and informal conversations with respected figures in orthodontics over the past 15 years. 

These are the reasons people or groups of like-minded “followers” do not accept research findings.

So here is the web of denial. This has trapped me for several years. I recently decided to stop engaging with these people, and my life is much simpler and happier.  

The web of denial.

I/we know best

This means that a person simply does not agree with the research findings. They prioritise their clinical experience over the research. In short, they are so confident in their clinical experience that they completely ignore research. This is the lowest level of rebuttal and perhaps reflects a degree of arrogance or ignorance of research methods. Unfortunately, this approach is becoming more common. This is a current tactic of the more extreme members of the airway-friendly community. Perhaps this reflects the way that modern politics is conducted.

You should have asked us?

I first became aware of this issue when we published the results of our studies on Class II treatment. After I had given conference presentations, it was not unusual for people to discuss my lecture. It was also common for delegates to express disappointment with our findings. Several felt it was regrettable that we had not consulted them about the treatment. They believed we had made mistakes in the design of our appliances and in the choice of mechanics. I even had someone stand up at the end of a lecture and say that “the reason we did not get much skeletal change from a Twin Block was because the design of the lower molar clasps was not correct.” 

They believed their advice would have kept the studies on the right track and that the findings would have agreed with their perceptions.

You did it wrong?

This was a rather blunt comment, and they stated that the study was flawed. Strangely, when I challenged them to point out the flaw, they could not do so.

Importantly, they put forward baseless reasons for rejecting research findings. For instance, they might feel that there were no relevant outcomes related to the treatments in which they believed . In effect, we had measured the wrong things. Theie other approach was to identify one minor flaw in the study and ignore the overall evidence.

These tendencies are becoming more common and are still baseless.

We would like a debate

The orthotropic dentists in the UK used this technique. It has recently been adopted by other airway orthodontists in the USA. The first step is to claim that the research is flawed. When this viewpoint is challenged, they ask for a debate. Occasionally, I and others, have agreed to this, but it has been a complete waste of time because the debate is a one-way conversation with a zealot who does not listen and simply expounds their theories ad nauseum. A complete waste of time.

You just need to listen to my podcast

This is a new social media approach to addressing research and is used in the USA. It is similar to asking for a debate. These people suggest that you listen to their podcast. I have looked at these, and they contain about 90 minutes of rambling discussion by one or more people who do a great job of misinterpreting the literature. In effect, they create a wall of irrelevant white noise. Again, a complete waste of time.

The study is not individualised

A common criticism of trials is that participants are treated as mere numbers rather than as patients who need individualised care. As a result, treatment protocols are so strictly defined that care cannot be tailored to individual needs. This means that the investigators do not evaluate the true “art of orthodontics”.

I believe this is incorrect. We must remember that trial operators have an ethical obligation to provide the best possible care to patients. This means they need to adapt their methods to ensure optimal treatment. Additionally, this approach helps maintain the study’s external validity. Furthermore, it would be unethical for them to treat a patient strictly according to the study protocol if they recognise that it could cause harm.

My patients are different.

This is when the person dismisses the findings because they are not applicable to their patients. This suggests that their patients differ significantly in genetic, sociological, and morphological aspects from those involved in the trial. There is not much more to elaborate about this ridiculous concept.

My AI-powered search does not agree.

This is a new one. They simply load the subject into their favourite AI system and ask for an appraisal of the evidence. However, these appraisals currently include all levels of evidence. As a result, the conclusions are not always correct. I realise that this area is changing rapidly and that AI appraisal is likely to become more accurate. At the moment, it is not, and anyone who adopts this approach is somewhat naive.

My information dump of papers does not support your findings.

This is another new method of denial. It involves downloading many references and abstracts and simply dumping them into a conversation without any critical appraisal or even reading the references. This overloads anyone having a discussion, and they tend to give up. Several Facebook-based orthodontists make extensive use of this tactic.

Pyramid of denial bingo

When I read the comments on a study, I often play a game similar to bingo by tallying the number of times “denial” is mentioned. I can’t help but notice a correlation between the frequency of these “denial” references and the level of quackery present.

Final thoughts

We need to remember that research is not automatically correct; studies can be flawed, but objections should be grounded in genuine critical appraisal: study design, bias, sample, outcomes, effect size, applicability, and replication. This is genuine scientific debate.

I thought that it would be worth revisiting these points so that we can refresh our memories. Let’s chat about this in the comments.

       

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A highly regarded team from the University of Washington did this study. The Angle Orthodontist published the paper.

Comparison of outcomes in adolescents treated with aligners versus fixed appliances.

Dayton S. Oki et al

Angle Orthodontist, DOI: 10.2319/100725-841.1

What did they ask?

They did the study to answer the following question. 

“What is the treatment efficacy and efficiency of clear aligners compared to fixed appliances for a population of adolescent patients?” 

What did they do? 

They conducted a retrospective study using readily available records. 

They used records from orthodontic patients aged 18 years or younger who were treated with a non-extraction approach or with one lower incisor extraction. Importantly, all records had to be available and adequate. The team selected these cases from the orthodontic clinic database, which contained records for 286 aligner patients. 

They also selected individuals treated consecutively with fixed appliances in the same orthodontic clinic during the same time period as the aligner group, using similar inclusion criteria. They matched on age, gender, pre-treatment arch length, and pre-treatment peer assessment rating score. 

The study cases were scored using the peer assessment rating system. 

They also reviewed the pre- and post-treatment intra-oral photographs to measure the presence and extent of any new or larger white spot lesions. 

They performed a sample size calculation based on the percentage of teeth that developed new white spot lesions. This indicated that they needed to examine the records of 29 patients per group. 

Finally, they conducted relevant univariate analyses. 

What did they find? 

Out of a total sample of 286 aligner patients, 255 did not meet the inclusion criteria, leaving 29 aligner patients in the study. A final sample of 29 fixed-appliance patients who met the inclusion criteria was selected. 

Each group consisted of 18 males and 11 females, with a mean age of 13.9 years. All patients had no extraction treatment, except for one fixed appliance patient who had a lower incisor extraction.

There were no marked differences between the groups at the start of treatment. 

Importantly, the mean pre-treatment PAR score for the aligner group was 23.4 (8.7) points, whereas for the fixed appliance group, it was 24.1 (9.1). These are mild to moderate malocclusions.

At the end of treatment, the post-treatment PAR score for the aligner group was 5.8 (4.1) points, and for the fixed appliance group, it was 7.1 (3.6) points. This indicates a degree of residual malocclusion.

The total treatment time for the aligner group was 22.8 (6.2) months, and for the fixed appliance group, this was 23.7 (4.0) months. These differences were not statistically significant. Yet, for the number of visits, the aligner group had a mean of 15.7 visits, while for the fixed appliance group, this was 21.3. This difference was statistically significant. 

Finally, they looked at new or larger white spot lesions. There were no statistically significant differences between the two groups. 

Their final conclusions were 

“Adolescent patients with mild to moderate malocclusions had similar post-treatment occlusal outcomes when treated with aligners versus fixed appliances”.

“Although the overall treatment times between the two groups were similar, the aligner patients had significantly fewer scheduled visits.”

What did I think? 

This study provided useful information on the overall efficiency and efficacy of clear aligners compared with fixed appliances. Treatment outcomes were similar. Aligners may reduce the appointment burden, emergency visits, and the development of white spot lesions. 

However, we do need to be somewhat cautious about this study. This is because it was a small retrospective study involving 58 patients at a single clinic. Importantly, treatment allocation was not random. This matters when we consider that patients selected one type of treatment over another. As a result, this study has selection bias, and we need to bear this in mind when considering the findings. Furthermore, we have no information on the completion rates of the treatment. This is very important when we consider the removable nature of the clear aligners.

We also need to consider that according to the PAR scores, these were mild to moderate malocclusions treated on a non extraction basis.

Finally, this study was supported by Align Technology, and the authors clearly stated this.

Nevertheless, I believe this is a positive step forward in aligner research. It indicates that, for certain cases with mild to moderate malocclusion, aligners could be a practical treatment option. Of course, more research is needed, especially the long-overdue RCTs aligners that may never come to fruition! 

       

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This is important because there is little regulation of social media. As a result, there is a danger of claims being made for the benefits of treatment that cannot be realised. 

This interesting problem has been looked at by a team based in London and Dublin. The British Dental Journal Open published this paper. 

A qualitative exploration of orthodontists’ perceptions of social media marketing of orthodontics

Amardeep Dhadwal, 1Dominic Hurst 2and Padhraig S. Fleming

BDJ https://doi.org/10.1038/s41415-026-9795-3

What did they ask? 

They did this study too. 

“Explore orthodontist perceptions of social media marketing of orthodontics using qualitative methodology.” 

What did they do? 

They conducted a qualitative study using semi-structured one-to-one participant interviews conducted via video conferencing. The team invited members of the British Orthodontic Society to take part in the study. 

They used a pre-piloted topic guide to enable in-depth exploration during the interviews. They recorded and transcribed the interviews and analysed them using manual coding. Finally, they used an interpretive approach with thematic analysis. 

The team interviewed a sample of twelve orthodontists. Data saturation was reached after ten interviews. 

What did they find?

It is difficult to report in detail on a qualitative research paper; however, I am going to try to draw out the main points of their findings. 

Uneven playing field

The first theme they identified was an uneven playing field. The participants thought that social media marketing was dominated by companies who tended to advertise aligner-based products or direct-to-consumer orthodontics. This was also compounded by general dental practitioners advertising aligner-based orthodontics. They felt that these groups trivialised conventional orthodontic treatment modalities and incorrectly suggested the superiority of other treatments which lacked substance. 

Importantly, several of the participants felt that general dental practitioners face less scrutiny as non-specialists about the claims that they’re making. They also felt that social media marketing by orthodontists was rather sparse and that orthodontists did not necessarily share their opinions. 

Unsafe expectations and misinformation

This was the second theme. Participants expressed concern that social media marketing currently creates false expectations among patients and the public, while failing to reflect the true realities of orthodontics. Many also worried about the risks posed by misinformation. They believed that social media tends to sensationalise certain treatment options. Importantly, cases are often cherry-picked, showcasing only the most satisfied patients and the best outcomes in an overly idealised way. 

Importantly, they believed that the public was more vulnerable to harm from misinformation than clinicians and was less likely to critically evaluate marketing posts. This raised concerns about potential risks of harm.  

Universalising social media marketing.

Theme three focused on universalising social media marketing. They emphasized that self-regulation could be a solution and highlighted the importance of orthodontists embracing social media to enhance acceptance and effectively counteract misinformation. 

Finally, they advised that orthodontists should engage in self-regulation by sharing accurate, evidence-based content, being truthful, and addressing any concerns. 

What did I think?

This study employed standard qualitative methods, which enable researchers to capture the perceptions of participant groups. Although some might view this as ‘soft data,’ it remains a valuable and insightful source of information.

The findings are significant because they clearly show that social media is primarily dominated by companies that operate without regulation. In addition, general dentists, who may lack specialized knowledge, might not be able to critically evaluate some of the claims being made.

The main implication is that current orthodontic social media aimed at patients may present information that targets vulnerable individuals. This is an important issue that needs to be addressed.

It is also important to note that orthodontists can sometimes face the same criticism. We can see this by looking at the popular US-based social media accounts that focus on breathing.

Finally, I believe that specialist societies should take action by promoting self-regulation and, more importantly, by increasing their activity on social media to confront the widespread misinformation currently circulating. The British Orthodontic Society has done a great job in this area. They have released statements on breathing and orthotropics and have taken action against some fringe orthodontists. I’m not sure if other societies have been so proactive. Perhaps non UK orthodontists could comment on this?

       

Comments

• Orthodontists promoting unproven procedures is certainly a ... by Skander Ellouze

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I thought this study was interesting because it evaluated a real-world clinical problem in a well-conducted small study. 

A team from India did this trial. The Angle Orthodontist published the paper. 

Clinical implications of recall visit ligature-tie activation on alignment efficiency in premolar extraction cases: a randomized controlled trial

Jayashree Karingha et al

Angle Orthodontist. Advance access: 

DOI: 10.2319/111425-942.1

What did they ask?

The aim of their study was to 

“Evaluate whether replacing stainless-steel ligature ties at each recall visit significantly enhances the efficiency of anterior de-crowding compared with maintaining the same ties throughout.” 

What did they do?

They conducted a prospective, single-blind, parallel-group randomised controlled trial. They registered the trial before the study began. 

The PICO was 

Participants:

Orthodontic patients aged 16 years or older, in good health, with moderate-to-severe anterior crowding who required premolar extractions. All received pre-adjusted edgewise braces. 

Intervention.

In this group, they did not replace the ligature ties at recall visits until they had resolved the anterior crowding. 

Comparator: 

In this group, they replaced the ties w at every 4-week recall visit. 

Outcomes:

The primary outcome was reduction in anterior crowding using Little’s irregularity index. They measured this from study casts for the initial study models and at each follow-up visit.

They calculated that they needed 12 patients in each group, but I couldn’t find any information about the expected difference used to determine this number.

Patients were randomly assigned to each group with a 1:1 ratio using an online tool. They kept the allocation by placing it in sealed envelopes.

Both the participants and the clinicians knew which group the patients were in. The data on Little’s Irregularity Index was collected using digital vernier calipers. 

What did they find? 

They enrolled 24 patients into the study. They excluded one participant because of repeated failures. 

There were no differences between the groups at the start of the study. 

When they examined the mean duration required for complete alignment of the anterior teeth, it was 68.73 ± 29 days in group 1 (ligature ties not replaced) and 65.33 ± 24.85 days in group 2 (ties replaced at each visit). This difference was not statistically significant. 

Their most important conclusion was:

“Replacing stainless steel ligature ties at each recall visit does not result in a clinically significant acceleration of anterior alignment during the initial phase of orthodontic treatment. Scheduling recall visits every eight weeks may increase efficient time management during the alignment phase.” 

What did I think? 

I always enjoy reading clinically relevant studies. The team conducted this study well, and it met most of the criteria for a good randomised clinical trial. My only concern is familiar to regular readers: this was a single-centre study restricted to the initial alignment phase, with a relatively small sample size. The findings may also be relevant only to extraction cases. 

One piece of information missing from this study was any reporting of treatment side effects. For example, did patients who were not seen every 4 weeks have more problems with archwires poking through the molar tubes? 

Nevertheless, the findings are interesting and may reflect our regular clinical experience. They certainly provide reassurance that it is possible to leave our patients with fully tied-in ligatures for longer than four weeks. 

It is nice to return to studies about day-to-day orthodontic treatment, and this study is a small addition to our literature. 

       

Comments

• I remember I read a blog post here for several years ago about ... by VarroF
• Great to get evidence to back this up. I feel like we all ... by Chad B Carter
• They used stainless steel ligs and replaced them (or not)? I ... by Megan Hatfield
• This is exactly what we do when working with PSL, recall at 6 ... by Dr B
• I use self ligating brackets. Each one opens in half a second ... by Geoffrey Wexler

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