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Evidence based orthodontics /certified fixed orthodontic courses by Indian dental academy


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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

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Evidence based orthodontics /certified fixed orthodontic courses by Indian dental academy

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  2. 2. INDIAN DENTAL ACADEMY Leader in continuing dental education
  3. 3. Fasten your seat belts for the bumpy ride to evidence based practice.
  4. 4. Never discuss divergent views concerning religion and politics with friends, you could lose a friend and create an enemy.
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  6. 6. EVIDENCE Generally, an article published in a scientific journal- reporting results of a clinical trial- is considered as evidence.
  7. 7. EVIDENCE BASED DENTISTRY    Webster’s dictionary: judicious as exercising sound judgment. Defined : “ a conscientious explicit , and judicious use of current best evidence in conjunction with clinical experience to make decisions regarding patient care.” In other words, it is using evidence to base one’s therapeutic decision – making, rather than whim, instinct , or hearsay.
  8. 8.  ADA: “ an approach to oral health care that requires the judicious integration of systematic assessments of clinically relevant scientific evidence , relating to patient’s oral and medical condition and history, with the dentist’s clinical expertise and patient’s treatment needs and preferences.
  9. 9. Our literature is often inconclusive, inconsistent or even contradictory. This leaves clinicians frustrated, confused and skeptical of all research  EBO is not a cook book approach to orthodontics. 
  10. 10. EVIDENCE BASED DENTISTRY An approach to oral health care that requires the judicious integration of systemic assessments of clinically relevant scientific evidence, relating to the patients oral and medical condition and history, with the dentist’s treatment needs and preferences
  11. 11. PROCESS INTEGRATES 1. 2. 3. Clinical expertise Best research evidence Patient treatment needs
  12. 12. HISTORY OF EBD      Origin in the middle of 19 th century in Paris, when young graduates started challenging the validity of clinical decisions based solely upon personal experience. Mc Master University in Canada in 1985 , introduced some concepts in its curriculum. American College of Physicians followed. Establishment of Center for Evidence- based Medicine in Oxford, UK in 1995. The litigious nature of society further fueled the need for practicing evidence based health care
  13. 13. Faulty arguments against evidence based decision making     Dogmatic approach Influence of drug companies Academics Vs clinical research “Galileo ploy”
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  16. 16.    CONFOUNDING EFFECTS A goal of sound experimental research and design is the control of confounding factors. When factors are not controlled, the effects of treatment are clouded with the outside influence of extrinsic factors and the treatment effects cannot be isolated and analyzed. If the findings of confounded studies are accepted ,there is a strong possibility that this will negatively impact patient care.i.e.beneficial treatment will be ignored and useless treatment adopted.
  17. 17. CONTROLLING GROUP  Research does lend itself to the use of a control. nonetheless ,when controls are required and used, the liability and validity of a study are improved. with observational research vis-à-vis experimental research, the group not having treatment is often called the comparison or matched group rather than the control group. Through the use of a control group in experimentally designed studies, a researcher can assert with confidence that the treatment or condition introduced is directly responsible for the findings obtained, instead of due to chance or some other extraneous variable.
  18. 18. HAWTHORNE EFFECT   Despite the effectiveness of experiment design, potential threats can directly impact validity ,a time management study in 1930 at western electrics Chicago based Hawthorne plant desired to improve employee morale and particularly productivity. Reverse Hawthorne effect- resentment or apathy developing in control group which does not receive treatment. This produces poor behavior or improvement in control groups.
  20. 20. LEVELS OF EVIDENCE To judge the quality of studies a “hierarchy of evidence” exists the relative strength of various studies. The evidence that is most likely to be useful for making decisions regarding patient management: 1. Systematic Review (Meta-analysis) 2. Randomized Controlled Trials (RCTs) 3. Cohort Studies 4. Case-control Studies 5. Cross-sectional Surveys 6. Case Series/ Report
  22. 22. SYSTEMATIC REVIEWS       Systematic reviews are a synopsis of the existing evidence on a specific topic. Provides means to keep up with numerous articles published annually in every field. Concentrates on a very specific and narrow, clinically relevant question. Team of experts Inclusion and exclusion criteria is used Bias unlikely to happen
  23. 23. STEPS IN PERFORMING SYSTEMATIC REVIEW   1. 2. 3. 4. FIRST STEP : framing an important and well defined question that is relevant to patient care. Framing a question in a proper format and identifies four crucial “ PICO” elements. These elements are: Population or patient type Intervention Comparison Outcome
  24. 24.   SECOND STEP: determining inclusion and exclusion to select the eligible studies. Subcategory of outcome, exposure, confounder, effect modifiers, intermediates, type of control as well as type of study design and other consideration.
  25. 25.   THIRD STEP: design a search strategy. Employed to search available studies include both electronic databases such as MEDLINE, EMBASE, Web of science and Cochrane, databases and manual searches.
  26. 26.   FOURTH STEP: involves application of the selection criteria identified in step Two to the potential studies retrieved from both electronic and manual search strategies determined in step Three. This action will result in selection of the eligible studies for the review and appraising these studies.
  27. 27.   1. 2. 3. 4. 5. 6. FIFTH STEP: Performing a statistical summary of the abstracted data, or Meta- analysis. Data from different study designs are summarized with the purpose of the following six tasks: Deciding whether to combine the data or defining what to combine Evaluating the statistically heterogeneity of the data Estimating a common effect Exploring and explained heterogeneity Assessing the potential for bias Presenting the results in the form of a table
  29. 29. META ANALYSIS  It identifies the major varying factors for their significance, and reports that studies match their defined standardization criteria
  30. 30. RANDOMISED CONTROL TRIALS   An experimental study on patients with a particular disease or disease –free subjects in which the individuals are randomly assigned to either an experimental intervention or a control group to determine the ability of an agent or a procedure to diminish symptoms, to decrease risk of death from disease during follow up period. Provide strongest evidence causation of evidence.
  31. 31. Drawbacks:     Raise ethical concerns in control groups Costly and time consuming to implement Because of the strict eligibility criteria and loss to follow-up, RCT sample size requirements are difficult to attain and maintain, Result becomes in limited external validity of results for the general population
  32. 32. COHORT STUDIES       An observational study that follows an exposed cohort compared to an unexposed cohort to determine the incidence of given outcome. Well designed cohort study provides strong support for causation Non concurrent cohort studies are relatively weaker because they rely on existing records. Disadvantages : require large sample size Length of the studies result in misclassification in outcome status Continuous assessment of the exposure and outcome results.
  33. 33.     CASE CONTROL STUDIES These are observational studies where in cases with a particular outcome and controls that donot have the same outcome are first selected and exposure assessment is done retrospectively. Quick, relatively inexpensive Appropriate in studying rare diseases Assessment of multiple risk factors for a particular disease within the same study
  34. 34.    CASE REPORT AND CASE SERIES Document unusual occurrences of outcomes First clues of a new diseases or adverse effects of exposure Case series are an extension of case reports
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  36. 36.     HISTORY Early part of 19 century ushered in evidence based decision making for health care. 1920 Geis report- Medical and Dental schools to be scientific in their teaching. Dentistry and Orthodontics have lagged behind medicine in the quest to incorporate science in to clinical practice. Perhaps, the art in the practice of dentistry has overshadowed the need for science.
  37. 37. Making sense of Evidence    The evidence gathered is checked for its scientific validity, and applicability in patients. Why article not published in prestigious journal ? The RCT is considered to be ‘de rigueur’ for arriving at a scientifically valid conclusion.
  38. 38.    1. 2. 3. Necessary to know the type of randomization done, by going through the methodology of study. Element of blinding too should be apparent in the study. Even though the study is determined to be valid , still may not be applicable to one’s patient. Different characteristics of patient Results may be weak Statistical analysis may not be adequate
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  40. 40. Face mask protraction therapy in early skeletal Class III AJO DO 2005 128; 299-309     Does RME enhance the efficiency of maxillary protraction with face mask in developing Class III malocclusion? Results: Face mask therapy effective in early Class III MO The need for palatal expansion in the absence of a transverse discrepancy or a skeletal/ dental cross bite is not supported. Correction due to combined skeletal and dental change.
  41. 41. Critical appraisal EBD 2006:7,16-17.     First prospective RCT of the subject Inclusion of control group to quantify growth before recruiting participants. Results are conclusive. The skeletal change following protraction is significant, but has no correlation with expansion.
  42. 42. Skeletal and dental changes with fixed slow maxillary expansion treatment. Systematic review. JADA Feb 2005    Eight studies were selected, each lacked a control group, and four also did not have a measurement error treatment. A control group is necessary to factor out normal growth changes in the dental arch and cranio facial structure. No strong conclusion could be made on dental and skeletal changes after SME.
  43. 43. Meta analysis of immediate changes with RME treatment JADA Jan 2006   Results: Of the 31 selected abstracts, 12 were rejected b coz they failed to report immediate changes after the activation phase of RME and instead reported changes only after the retention phase. The greatest changes were in the maxillary transverse plane in which the width gained was caused more by dental expansion than true skeletal expansion. Few vertical and anteroposterior changes were statistically significant, and none was clinically significant.
  44. 44. A systematic review concerning early orthodontic treatment of unilateral posterior cross bite Angle Orthod 2003;73:588-596 The aim of this study was to assess the orthodontic treatment effects on unilateral posterior cross bite in primary and early mixed dentition by systematically reviewing the literature. Two RCT’s of early treatment of cross bite have been found and these two studies support grinding as treatment in the primary dentition. There is no scientific evidence to show which of the treatment modalities, grinding, quad helix, expansion plates or RME is most effective
  45. 45. Orthodontics and Temporo-mandibular Disorders – A meta-analysis AJO DO 2002;121:438-446 Orthodontists are blamed for causing TMD. Epedemiologic studies show that TMD symptoms are most prevalent among patients between 15-25 years of age. Orthodontists may encounter patients who complain about TMD during or after treatment. Does traditional orthodontic treatment change the prevalence of TMD? No study indicated that traditional appliance increased the prevalence of TMD, except for mild or transient signs
  46. 46. The effect of topical fluorides on decalcification in patients with fixed orthodontic appliances: A systematic review AJO DO 2005; 128: 601-606 Decalcification is a significant problem during fixed orthodontic treatment. Topical fluorides can reduce or eliminate the problem, but the relative effectiveness of different or combinations of topical fluoride preparations is unknown. Results: The use of topical fluorides in addition to fluoride toothpaste reduced the incidence of decalcification in populations with both fluoridated and non fluoridated water supplies. Different preparations and formats appear to decrease decalcification but there was no evidence that any one method was superior.
  47. 47. Incremental versus maximum bite advancement during Twin block therapy: A randomized controlled clinical trial. AJO-DO 2004;126:583-8 •Experimental patients had 2mm initial bite advancement and subsequent 2mm advancements at 6 weekly intervals with a Twin block appliance incorporating advancement screws. •The aim of this study was to evaluate the effectiveness of incremental and maximum bite advancement during treatment of class II div 1 malocclusion with the Twin-block appliance in the permanent dentition. •The use of incremental advancement of the twin block did not confer any advantage in terms of process and outcome of the treatment.
  48. 48. Outcomes in a 2-phase RCT of early class II treatment AJO DO 2004;125:657-667 This study was a randomized control trial designed to examine the 2 major strategies used to treat class II malocclusion:early treatment in mixed dentition before adolescence,followed by a second phase of comprehensive treatment in permanent dentition;and 1-phase treatment during the adolescent growth spurt and early permanent dentition. Results: there was no differences in the findings between the ‘intent to treat’(ITT) sample,who had completed phase 1,and an ‘efficacy analyzable’(EA)sample(n=137),which comprised only patients who completed phase 2.During phase 2 of the trial,the advantage created during phase 1 treatment in the 2 early treatment group was lost,and by the end of fixed appliance treatment,there was no significant difference between any of the 3 groups for all anteroposterior and vertical skeletal and dental measures.
  49. 49. CONCLUSION  Currently, researchers and facilitating organizations disseminate best evidence in the forms perceived logical for clinical practice .These forms are standard to research reporting. Once reported, evidence must be read,analyzed,and accepted for its statistical significance.Then,findings need to be integrated with other types of evidence to provide statistically component comparisons and measures of decision making.
  50. 50. REFRENCES 1. Incremental versus maximum bite advancement during twin block therapy : A randomized controlled clinical trail- Phil Banks, Jean Wright & Kevin O’Brein (AJODO 2004; 126: 583-8) 2. Outcomes in a 2-phase randomized clinical trail of early Class II treatment- J.F.Camilla Tulloch, William R. Proffit & Ceib Phillips (AJODO 2004; 125: 657-67) 3. Essential elements of evidenced- based endodontics: Steps involved in conducting clinical research- Mahmoud Torabinejad & Khaled Babjri (JOE 2005; 35: 563-8) 4. The effect of topical fluorides on decalcification in patients with fixed orthodontic appliances: A systematic review- Barbara L Chadwick, Jayne Roy, Jeremy Knox & Elizabeth T Treasure (AJODO 2005; 128: 601-6) 5. Orthodontics & temporomandibular disorder: A meta- analysisMyung- Rip Kim, Thomas M Graber & Marlos A Viana (AJODO 2002; 121: 438-46)
  51. 51. 6. Making the case for evidence- based orthodontics- Greg J Huang (AJODO 2004; 125: 405-6) 7. Putting the evidence first- David L Turpin (AJODO 2005; 128: 415) 8. Effect of Herbst treatment on temporomandibular joint morphology: A systematic literature review- Kurt Popowich, Brain Nebbe & Paul w Major (AJODO 2003;123: 388-94) 9. Evidence - based versus experience- based views on occlusion & TMD- Donald J Rinchuse, Daniel J Rinchuse & Sanjivan Kandasamy(AJODO February 2005,Volume 127,Number 2) 10. Fasten your seat belts for the bumpy ride to evidence-based practice.Greg J.Huang(AJODO,Volume 127,Number 1) 11. Understanding science and evidence-based decision making in orthodontics-Donald J Rinchuse,Emily M.Sweitzer,Daniel J.Rinchuse,Dara L.Rinchuse,AJODO,Volume 127,Number 5) 12. Model of Evidence-Based Dental Decision Making,Janet Baeuer,Sue Spackman,Francesco Chiappelli,Paolo Prolo(Journal of Evidence-Based Dental Practice 2005;5:189-97)
  52. 52. 13.Evidence-Based therapy:An Orthodontic dilemmaAnthony Gianelly(AJODO,Volume 129,Number 5) 14.A Systematic Review Concerning Early Orthodontic Treatment Of Unilateral Posterior Crossbite-Sofia Petren,Lars Bondemark,Bjorn Soderfeldt,Med Sc(Angle Orthodontist,Volume 73, Number 5,2003) 15. Face mask protraction therapy in early skeletal class III malocclusion-Anmol S Kalha(EBD 2006:7.1) 16.Skeletal and dental changes with fixed slow maxillary expansion treatment-Manuel Lagravere,Paul Major,Carlos Floresmir(JADA,Volume-136,February 2005) 17. Meta-analysis of immediate changes with rapid maxillary expansion treatment-Manuel Lagravere,Giseon Heo,Paul Major,Carlos Flores Mir(JADA,Vol.137,January 2006)
  53. 53. Leader in continuing dental education