Simon Littlewood, who is an authority on retention, based in Bradford, Yorkshire wrote this paper. The American Journal of Orthodontics published his paper.

Post-treatment orthodontic care for retention and stability

Simon Littlewood

AJO-DDO. https://doi.org/10.1016/j.ajodo.2026.01.025

This paper is not open access, so reading the full text is not easy. This is a shame, and I wonder whether the AJO-DDO could make this paper freely available so that this knowledge can be shared?

I would like to declare an interest, as I know Simon Littlewood well. 

His aim in writing this paper was to

“Outline the current status of orthodontic retention, based on the results of clinical research, clinical experience, and patients’ perceptions”. 

There is a large amount of useful information in this paper. It is difficult for me to summarise it all, but I will do my best to outline the main points.

The inevitability of relapse 

We are all familiar with the University of Washington publications from the 1970s. These show that relapse is unpredictable and that it is not possible to predict which patients will remain stable. We also know that relapse may be related to post-retention factors such as facial growth and natural ageing. As a result, we should remember that relapse is inevitable. Nevertheless, we should take steps to retain our final treatment occlusion as far as we can. 

Clinical expertise 

To consider evidence-based retention, we must immediately consider the role of clinical expertise. Although there have been many studies on methods of orthodontic retention, it is clear that the results of these studies are influenced by the operator’s skill and experience. This is similar to most areas of orthodontic treatment. 

Patient values. 

Patients need to consider the effects of their attitudes, expectations, and willingness to undertake certain forms of treatment. This is perhaps the most important factor when we consider retention, as we know our patients need to develop a long-term commitment to reduce unwanted change. 

Importantly, he points out that patients are more likely to wear their retainers if they establish a good pattern of retention wear immediately after the end of their treatment. Furthermore, they report that they wear their retainers because they don’t want to disappoint their clinician, and it is always important for them to have a spare set of retainers in case they are lost. 

Research evidence 

In this section, he draws heavily on the recent Cochrane review, which includes data from 47 randomised trials. Unfortunately, he points out that the evidence on retention remains relatively low, making it difficult to recommend a particular approach at present. There is a clear need for longer-term studies. He uses some of the evidence from this review in the later sections of his publication. 

Types of retainers Fixed retainers 

Most of us have used fixed retainers for our patients. This is because they offer the clear advantage of not requiring compliance to wear them. There is little effect on retention between the different types of wire retainer that can be used. Recently, there have also been developments in CAD/CAM technology. However, there is little evidence to support their increased effectiveness with this new technology. Nevertheless, this may offer clinicians a better and more efficient workflow. 

When we consider the failure rate of bonded retainers. This is surprisingly high, at approximately 35%. Other disadvantages include the potential to increase the risk of plaque and calculus buildup, which may lead to long-term periodontal problems, although long-term studies are lacking. 

The final potentially serious problem with bonded retainers is wire syndrome, in which unwanted bends in the wire cause excessive tooth movement, leading to severe periodontal defects and tooth loss. In this respect, it is essential to regularly review retainers. 

Removable retainers 

In this section of the paper, he outlines the differences in effectiveness between Hawley and clear plastic retainers. Additionally, he points out that high-quality research shows that clear plastic retainers can offer some advantages over Hawley retainers. Moreover, importantly, patients tend to prefer clear retainers because of their better aesthetics. Furthermore, the results of RCTs also show that removable retainers are normally worn at night. They do not need to be worn full time.

When we consider the potential harmful effects of plastic retainers, there are recent concerns about microplastic leaching from these. However, the research is in its early stages, and we urgently need further research in this area. 

Nevertheless, we do need to bear this theoretical problem in mind when discussing retainers with our patients. 

The choice or removable or fixed retainers 

I think one of the major issues in retention is the choice between fixed and removable retainers. I went through several phases, preferring different types of retainers throughout my career, and eventually leaned towards clear removable retainers in my last few years of clinical practice. 

Simon points out that most evidence shows that within the first 6 to 18 months, there’s little difference in the effectiveness of fixed and removable retainers. There are, of course, several advantages and disadvantages of each of these methods, and he has provided this information in a clear table within the article. This provides a useful source of information for discussions with our patients. 

Shared decision making 

The final section of this paper addressed shared decision-making with our patients. Importantly, he points out that shared decision-making means taking treatment decisions with our patients rather than about them, and this has been shown to increase cooperation with treatment regimes. 

This means it is very important for us to discuss the advantages and disadvantages of the different types of retainer with our patients. This also brings me to retention review. It is clear that there is a need for long-term review of any form of retention, and the responsibility is shared among the orthodontist, the patient, and the general dentist.

In this respect, it is not acceptable to discharge patients and inform them that their general practitioner will look after the retainer. A more reasonable approach is to ensure that the general dentist understands the importance of retention, knows how to monitor retainers, and can make repairs. As a result, it is important that knowledge and skills related to monitoring retention should be included in undergraduate and Continuing Professional Development Courses. I cannot help thinking that this is easier said than done and may be the weak link in providing orthodontic retention. 

His overall conclusion was 

“Absolute stability after orthodontic treatment is not feasible, but it is possible to reduce unwanted post-treatment changes with appropriate use of retainers”. 

He has outlined this nicely in this paper. 

What did I think? 

It is unusual for me to review a summary paper. However, I thought this one was so useful that it was worth sharing more of the knowledge it contains. 

If we consider that the three components of evidence-based care are clinical experience, research evidence, and patient perceptions, then Simon has covered these very well in this publication.

Importantly, he has relied heavily on research evidence, much of which comes from randomised trials. He combines this very well with clinical experience and a substantial body of research on patients’ perceptions.

As a result, I feel this is an excellent publication, and we should all consider its conclusions when providing retention care for our patients. 

       

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I have previously posted about the first part of the study.

Patient Harm From Orthodontic Care (Part II): Incident Analysis of Contributory Factors and Perceived Avoidability of Harm

Nikolaos Ferlias, Athanasia Grigoroudi, Julian Woolley, Sukeshana Srivastav, Henrik P. Nielsen and Peter Stoustrup

Orthodontics & Craniofacial Research, 2026

https://doi.org/10.1111/ocr.70172

I have previously posted about the first part of the study.

What did they ask?

They did this study to:

1. Identify the factors contributing to patient harm;
2. Estimate whether the harm was avoidable;
3. Explore the relationship between avoidability and the number and type of contributory factors; and
4. Suggest ways of reducing future incidents.

What did they do?

The authors examined 125 orthodontic claims approved for compensation by the Danish Dental Compensation Association from September 2019 to August 2024. They aimed to identify the factors contributing to harm and estimate how much of it might have been avoided.

An experienced orthodontist reviewed the clinical records, radiographs, photographs, correspondence and compensation decisions for each claim.

The reviewer classified possible contributory factors using the Eindhoven Classification Model. These included:

• human factors, such as monitoring, verification and clinical knowledge;
• organisational factors, such as protocols, management priorities and workplace culture;
• technical factors involving appliances or materials; and
• patient-related factors.

The same reviewer then rated the avoidability of each incident on a six-point scale, from completely unavoidable to completely avoidable.

Finally, the authors grouped the cases into low-, moderate- and high-avoidability categories. They used ChatGPT to help develop qualitative descriptions of the patterns and possible mitigation strategies. The authors state that the AI did not review patient records, identify contributory factors, or determine whether harm was avoidable.

What did they find?

The most common categories of compensated harm were:

• Gingival or other soft-tissue harm: 17%;
• Apical root resorption leading to tooth loss: 15%;
• Worsening of the occlusion following treatment: 11%;
• Cervical root resorption leading to tooth loss: 10%; and
• Damage to a tooth crown: 7%.

Just over half of the harm-causing events occurred during active orthodontic treatment. Delayed diagnosis accounted for 22%, while retention-related incidents accounted for 10%.

The authors identified a median of five contributory factors per case. Monitoring and verification problems were the most common, occurring in 56% and 54% of cases, respectively. They recorded deficiencies in clinical knowledge and professional qualifications in approximately 42%.

Organisational factors were also common. These included management priorities, workplace culture, inadequate protocols, and ineffective knowledge transfer between team members.

Patient-related factors were identified in 45% of the compensated cases. This does not necessarily mean that patients “caused” the harm. It indicates that factors such as biological variation or cooperation may have formed part of a more complicated chain of events.

Finally, they concluded that 82 incidents were probably, highly or completely avoidable. They reported this as 70.1% of the claims assessed for avoidability.

Cases considered highly avoidable tended to contain more contributory factors. In other words, serious, avoidable harm often appeared to stem from several failures interacting rather than from a single isolated mistake. This is similar to other “never” events that arise from a series of unfortunate events. 

Their conclusions were

“70% of the compensated cases were avoidable and most harms were mutltifactorial in nature.”

What did I think?

This is an important paper because patient safety receives surprisingly little attention in orthodontic research. We devote considerable effort to comparing appliances and measuring small differences in treatment efficiency. Avoiding tooth loss, periodontal damage or a missed diagnosis is likely to be far more important to patients.

The use of a national, no-fault compensation scheme is also a strength. Patients did not need to establish malpractice before applying, which may reduce some barriers found in litigation-based datasets. The investigators reviewed detailed clinical material rather than relying only on brief incident reports.

The central message is both plausible and useful. Harm often develops when monitoring, verification, communication and clinical systems fail together. Simply identifying and blaming the last clinician in the chain is unlikely to prevent the next incident.

Limitations

As with all studies, there are some limitations that influence our certainty about the findings.

Most importantly, these 125 cases were not a random sample of orthodontic treatment. They were approved compensation claims. They are consequently likely to represent unusually severe or readily identifiable harm. We cannot use this study to estimate the risk of being harmed during orthodontic treatment, nor can we conclude that 70% of all orthodontic complications are avoidable.

Additionally, only one investigator performed both the incident analysis and the avoidability assessment. Even though this was an experienced reviewer using a structured system, this is still a structured judgement. The authors did not test agreement with a second assessor or repeat the ratings to assess the reliability of the ratings.

Finally, I was not sure whether the AI-generated interpretations and recommendations were helpful. The important work was the human review and classification of the cases. Suggestions generated from those classifications remain suggestions; the study did not test whether checklists, protocols or additional training actually reduce orthodontic harm.

What can we learn from this paper?

I took from this paper that we should:

• monitor treatment actively;
• verify diagnoses, treatment decisions and critical procedures;
• arrange appropriate radiographic review when there is a risk of root resorption or damage associated with impacted teeth;
• establish clear routes for communication and referral;
• document the reasons for important decisions;
• use significant incidents as opportunities for team learning; and
• develop systems that make safe actions easier and unsafe omissions more difficult.

This may be obvious to many readers of my blog. But patient safety requires competent clinicians working within practices that support communication, verification, reflection and timely action.

Final thoughts

This was an interesting and worthwhile study of a neglected area.

The findings suggest that, among a selected group of compensated incidents, many harms were considered avoidable and usually involved several unfortunate events.

I think the 70% estimate is only a rough estimate. However, the wider conclusion is convincing: monitoring, verification and good clinical systems are important.

       

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This new study looked at the effectiveness of corticotomy-assisted RME and protection in late adolescence.  

A team from Turkey did the study. The American Journal of Orthodontics published the paper. 

Corticotomy-assisted rapid maxillary expansion and maxillary protraction therapy in late adolescence: Evaluation of 3-dimensional stereophotogrammetric soft-tissue, cephalometric, and 2-dimensional airway changes: A prospective controlled clinical trial

Coban et al. 

AJO-DDO https://doi.org/10.1016/j.ajodo.2026.05.014

What did they ask?

This study was conducted to find out protraction.

“The short-term effects of corticotomy-assisted RME and face mask therapy in late adolescent patients with skeletal Class 3 malocclusion compared with no treatment” 

What did they do? 

They did a prospective single-centre, non-randomised, controlled clinical study. 

The sample in this study was formed of orthodontic patients aged 13 to 16 years with a true skeletal Class 3 malocclusion with maxillary deficiency and an anterior crossbite. The investigators allocated them to two groups:

16 patients received corticotomy-assisted rapid maxillary expansion followed by face mask treatment.

16 received no treatment during a comparable observation period.

The patients underwent bilateral maxillary corticotomies under general anaesthesia. The surgeons raised mucoperiosteal flaps and made cortical cuts extending from the piriform aperture towards the pterygomaxillary region.

After expansion, the patients wore a facemask for 14–18 hours per day, applying 750–1000 g of force on each side. Treatment continued until they achieved a Class I occlusion and a positive overjet. The mean treatment duration was approximately 8 months.

Outcomes

The investigators collected lateral cephalograms and 3D facial photographs before and immediately after treatment. Their primary outcome was the position of Point A relative to the nasion perpendicular. They also measured numerous skeletal, dental, airway and facial soft-tissue variables.

Importantly, they sought to address the large number of statistical comparisons by applying a false-discovery-rate correction to the secondary outcomes. They also performed adjusted analyses that accounted for baseline measurements, age, sex, treatment duration, and skeletal maturity.

What did they find?

They presented an incredible amount of data on the cephalometric airway and facial scan changes. This created a wall of confusing “white noise”.  I have never seen so much data in a single paper.

I do not have the space to go into most of these here; however, they reported that the  principal changes in the treated patients compared with the control group were  

• 2.35 mm greater forward change at Point A;
• 4° improvement in ANB;
• 6 mm improvement in overjet;
• 3.4° increase in the mandibular-plane angle;
• 4.3° retroclination of the lower incisors; and
• 3.3 mm relative posterior change in pogonion on the cephalometric measurement.

The 3D facial analysis showed changes consistent with increased facial convexity and forward movement around the base of the nose. Nasal alar width increased by 1.57 mm and alar-base width by 1.97 mm.

There were no clinically or statistically significant differences in the airway between the groups. However, this was measured from the cephalograams, so I doubt that this data was useful.

Their final conclusion was

“Despite reduced growth potential, corticotomy-assisted RME and face mask therapy produce short-term skeletal and soft tissue improvements in patients with true skeletal Class 3 malocclusion. However, long-term stability and randomised comparative data are required.” 

What did I think?

This was an interesting paper that gave us some important, clinically relevant information on treatment effects, which are logical.

The study was well done, and I have no doubt that it was difficult to carry out. They reported many outcomes, which led to the inclusion of numerous cephalometric and other tables. As a result, I found it impossible to assess all the variables. This paper would certainly have benefited from a more focused analysis.

However, we need to consider carefully whether the nature of the study influences our interpretation of the results. In this respect, I feel there are many reasons for us to be cautious. Importantly, the authors have highlighted nine shortcomings in their study. This is possibly the largest number of shortcomings that I have seen authors acknowledge in a paper in the American Journal of Orthodontics.

I feel that there are several major areas of concern. Firstly, this was not a randomised trial. The control group was self-selecting, as they declined treatment because of school or family obligations. This means that the study has considerable selection bias. This is because patients willing to undergo this rather invasive treatment may differ from those who decline it. While I do agree that the statistical analysis this team used may correct some of the unknown measurable differences, this is also unlikely given the small sample size. 

I was also confused, as it appeared that the cephalometric and scan data were not blinded. Therefore, we cannot exclude examiner bias in this study. 

My last major concern was that poor cooperation was an exclusion criterion. This was identified by parent reports, the absence of signs of wear on the appliances, and, most importantly, a lack of change in overjet during the first three or four months. This means that the sample analysed may have been biased towards those who respond well, which could exaggerate the apparent effectiveness of the treatment.  I could not find any information on the number of patients who were excluded because of poor co-operation.

Final comment. 

We need to bear in mind these methodological deficiencies when we consider these findings. There is no doubt that the clinical changes are interesting and large enough to be clinically valuable. However, the problems with selection bias, proficiency bias, and data bias are substantial. As a result, we should be very cautious in interpreting these findings for our clinical treatment. There is certainly a need for randomised trials in this very interesting area. 

       

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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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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. 

       

Comments

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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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