- Email: [email protected]
Guidelines for expanded orthodontic care
fill the roots. The other studies reported pulp obliteration of some degree in between 57.5% and 100% of the teeth. The percentage of replacement resorption, or ankylosis, was reported in four studies and ranged from 4.2% to 18.2%. Extraction was required in 78% of the teeth in one study and 6% in another. There was high heterogeneity among the studies. Surface resorption was noted in one tooth in one study and all teeth that suffered orthodontic rotation in another. For the teeth in three studies, inflammatory resorption was noted in 3% to 3.4% of the teeth. Extraction was done because of the condition in 16.7% of the teeth in one study and 2.63% in another. External root resorption developed in 34.6% of the teeth in one study. It led to extraction in 12.3% of the autotransplanted teeth. The effect size for surface resorption, inflammatory resorption, and external root resorption considered together was 19%, a considerable value. Heterogeneity among studies was extremely high, but decreased to a significant effect size of 4% when one study was excluded from the meta-analysis, as suggested by the sensitivity analysis.
Discussion.—The survival rate for autotransplantation in these studies was excellent (81%) with follow-up of at least 6 years. Prognosis was influenced by the development of ankylosis and root resorption.
Clinical Significance.—Autotransplantation can be challenging and should be performed by experienced and skillful surgeons who follow a careful surgical procedure with ongoing follow-up. The complications, especially ankylosis and root resorption, can be serious and lead to the extraction of the tooth in a number of cases. However, the high rate of survival long-term makes this an option that should be considered for patients seeking to replace a missing tooth.
Machado LA, do Nascimento RR, Ferreira DMTP, et al: Long-term prognosis of tooth autotransplantation: A systematic review and meta-analysis. Int J Oral Maxillofac Surg 45:610-617, 2016 Reprints available from LA Machado, Dept de Ortodontia, Faculdade de Odontologia, Universidade Federal Fluminense, Campus i, Valonguinho, Rua Mario Santos Braga, 30, sala 214, Centro, Nitero RJ CEP 24040-110, Brazil; e-mail: [email protected]
Orthodontics Guidelines for expanded orthodontic care Background.—Nearly half of all children and adolescents in the United States were covered by public insurance in 2014, most by Medicaid. Expansions in public coverage have resulted in increased dental care usage by young persons as adults make fewer dental visits. Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment benefit requires that all medically necessary orthodontic care be provided to beneficiaries from birth to age 21 years sufficiently to address individual needs. This mandate for ‘‘medically necessary’’ orthodontic services does not set a standardized definition of medical necessity, instead leaving it to the states. As a result, the interstate variability in the criteria used to qualify patients for orthodontic care is both wide and biologically implausible. Substantial latitude has also been granted to the states to determine administrative policies, including prior authorization processes, payment levels, payment
mechanisms, contracting arrangements, and reporting. Thus payment rates and submission procedures also vary widely and are economically implausible. How this system to provide orthodontic services can meet beneficiaries’ needs, improve treatment experiences, create better outcomes, and lower costs was evaluated. Policy Requirements.—A standardized policy that applies across the United States is needed. This should ensure that the enhanced dental prevention benefits for publically insured children will be delivered. A promise has been made to reduce orthodontic-related caries risks and experiences for children covered under the policy. Steps that are needed include more frequent dental prevention visits to primary care dentists, frequent application of fluoride varnish, and the use of sealants. Many states have already established practice acts that permit medical and dental
Volume 61
Issue 6
2016
331
providers to deliver frequent fluoride varnish treatments in an effort to address early childhood caries. The orthodontic benefit for Medicaid beneficiaries under age 21 years can be modeled on these programs. Actions to be Taken.—After orthodontic care begins, the orthodontist coordinates caries management strategies with the primary care dentist. This ensures that an individualized caries suppression program that fits the patient’s caries risk and experience and aggressively addresses early caries is being pursued. The state orthodontic societies are encouraged to work with state Medicaid personnel and vendors to ensure the Early and Periodic Screening, Diagnostic, and Treatment periodicity guidelines provide for more frequent caries management visits to primary care dentists and frequent varnish placement by orthodontists. All of these should be covered by the program at reasonable rates. Authorization for orthodontic care should be withheld from patients who do not achieve a satisfactory level of caries risk reduction. Once risk reduction is demonstrated, the orthodontic care can be delivered. This ensures that the orthodontic treatment does not increase caries risk. Orthodontic visit frequency should be based on a consideration of caries risk. In this way, children at higher
risk will be seen more frequently whether or not more visits are needed for orthodontic purposes only. With better caries risk assessment tools, the state process for approving Medicaid coverage of orthodontic treatment should incorporate a caries risk assessment component. High- and medium-risk children should have their needs addressed before bonding. This is in accordance with the care paths and protocols in the American Academy of Pediatric Dentistry’s Guideline on Caries Risk Assessment and Management for Infants, Children, and Adolescents.
Clinical Significance.—The oral health of children and adolescents can be improved by instituting the suggestions offered in this article. This improved oral health and access to quality orthodontic treatment should allow poor and low-income youth to have better oral healthLrelated quality of life.
Cruz CL, Edelstein BL: Linking orthodontic treatment and caries management for high-risk adolescents. Am J Orthod Dentofacial Orthop 149:441-442, 2016 Reprints not available
Lingual and labial orthodontic appliances Background.—Orthodontic appliances are traditionally fixed on the outer (labial) surface of the teeth, but with more adult patients seeking orthodontic treatment and their increased demands for esthetic options, more appliances fixed on the inner (lingual or palatal) surface of the teeth are being placed. A comparison of the treatment effects of lingual appliances and labial appliances was undertaken. Methods.—Thirteen papers (11 clinical trials) were identified from a review of six electronic databases. Four were randomized controlled trials (RCTs) and seven nonrandomized trials. A total of 407 patients (34% male) were included in the review.
noticeability, less cheek discomfort, greater increase in intercanine width, less anchorage loss of the posterior segment during space closure, and fewer white spot lesions. Their disadvantages included greater oral hygiene problems, specifically with food impaction; worse oral hygiene as determined by plaque index; greater tongue discomfort; more oral pain and discomfort; more overall soft tissue irritation; more general activity problems; increased sleep disturbances; worse speech performance; higher sense of articulation alteration; more avoidance of some types of conversations; and more problems with eating. A single trial was the source for most of these comparisons. In addition, the problems were often limited to the initial month after placement of the appliances.
Results.—Compared to labial appliances, the beneficial effects of lingual appliances were as follows: less appliance
Discussion.—Most of the trials evaluated are small, nonrandomized, and cover only short-term adverse effects.
332
Dental Abstracts
Discussion.—The survival rate for autotransplantation in these studies was excellent (81%) with follow-up of at least 6 years. Prognosis was influenced by the development of ankylosis and root resorption.
Clinical Significance.—Autotransplantation can be challenging and should be performed by experienced and skillful surgeons who follow a careful surgical procedure with ongoing follow-up. The complications, especially ankylosis and root resorption, can be serious and lead to the extraction of the tooth in a number of cases. However, the high rate of survival long-term makes this an option that should be considered for patients seeking to replace a missing tooth.
Machado LA, do Nascimento RR, Ferreira DMTP, et al: Long-term prognosis of tooth autotransplantation: A systematic review and meta-analysis. Int J Oral Maxillofac Surg 45:610-617, 2016 Reprints available from LA Machado, Dept de Ortodontia, Faculdade de Odontologia, Universidade Federal Fluminense, Campus i, Valonguinho, Rua Mario Santos Braga, 30, sala 214, Centro, Nitero RJ CEP 24040-110, Brazil; e-mail: [email protected]
Orthodontics Guidelines for expanded orthodontic care Background.—Nearly half of all children and adolescents in the United States were covered by public insurance in 2014, most by Medicaid. Expansions in public coverage have resulted in increased dental care usage by young persons as adults make fewer dental visits. Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment benefit requires that all medically necessary orthodontic care be provided to beneficiaries from birth to age 21 years sufficiently to address individual needs. This mandate for ‘‘medically necessary’’ orthodontic services does not set a standardized definition of medical necessity, instead leaving it to the states. As a result, the interstate variability in the criteria used to qualify patients for orthodontic care is both wide and biologically implausible. Substantial latitude has also been granted to the states to determine administrative policies, including prior authorization processes, payment levels, payment
mechanisms, contracting arrangements, and reporting. Thus payment rates and submission procedures also vary widely and are economically implausible. How this system to provide orthodontic services can meet beneficiaries’ needs, improve treatment experiences, create better outcomes, and lower costs was evaluated. Policy Requirements.—A standardized policy that applies across the United States is needed. This should ensure that the enhanced dental prevention benefits for publically insured children will be delivered. A promise has been made to reduce orthodontic-related caries risks and experiences for children covered under the policy. Steps that are needed include more frequent dental prevention visits to primary care dentists, frequent application of fluoride varnish, and the use of sealants. Many states have already established practice acts that permit medical and dental
Volume 61
Issue 6
2016
331
providers to deliver frequent fluoride varnish treatments in an effort to address early childhood caries. The orthodontic benefit for Medicaid beneficiaries under age 21 years can be modeled on these programs. Actions to be Taken.—After orthodontic care begins, the orthodontist coordinates caries management strategies with the primary care dentist. This ensures that an individualized caries suppression program that fits the patient’s caries risk and experience and aggressively addresses early caries is being pursued. The state orthodontic societies are encouraged to work with state Medicaid personnel and vendors to ensure the Early and Periodic Screening, Diagnostic, and Treatment periodicity guidelines provide for more frequent caries management visits to primary care dentists and frequent varnish placement by orthodontists. All of these should be covered by the program at reasonable rates. Authorization for orthodontic care should be withheld from patients who do not achieve a satisfactory level of caries risk reduction. Once risk reduction is demonstrated, the orthodontic care can be delivered. This ensures that the orthodontic treatment does not increase caries risk. Orthodontic visit frequency should be based on a consideration of caries risk. In this way, children at higher
risk will be seen more frequently whether or not more visits are needed for orthodontic purposes only. With better caries risk assessment tools, the state process for approving Medicaid coverage of orthodontic treatment should incorporate a caries risk assessment component. High- and medium-risk children should have their needs addressed before bonding. This is in accordance with the care paths and protocols in the American Academy of Pediatric Dentistry’s Guideline on Caries Risk Assessment and Management for Infants, Children, and Adolescents.
Clinical Significance.—The oral health of children and adolescents can be improved by instituting the suggestions offered in this article. This improved oral health and access to quality orthodontic treatment should allow poor and low-income youth to have better oral healthLrelated quality of life.
Cruz CL, Edelstein BL: Linking orthodontic treatment and caries management for high-risk adolescents. Am J Orthod Dentofacial Orthop 149:441-442, 2016 Reprints not available
Lingual and labial orthodontic appliances Background.—Orthodontic appliances are traditionally fixed on the outer (labial) surface of the teeth, but with more adult patients seeking orthodontic treatment and their increased demands for esthetic options, more appliances fixed on the inner (lingual or palatal) surface of the teeth are being placed. A comparison of the treatment effects of lingual appliances and labial appliances was undertaken. Methods.—Thirteen papers (11 clinical trials) were identified from a review of six electronic databases. Four were randomized controlled trials (RCTs) and seven nonrandomized trials. A total of 407 patients (34% male) were included in the review.
noticeability, less cheek discomfort, greater increase in intercanine width, less anchorage loss of the posterior segment during space closure, and fewer white spot lesions. Their disadvantages included greater oral hygiene problems, specifically with food impaction; worse oral hygiene as determined by plaque index; greater tongue discomfort; more oral pain and discomfort; more overall soft tissue irritation; more general activity problems; increased sleep disturbances; worse speech performance; higher sense of articulation alteration; more avoidance of some types of conversations; and more problems with eating. A single trial was the source for most of these comparisons. In addition, the problems were often limited to the initial month after placement of the appliances.
Results.—Compared to labial appliances, the beneficial effects of lingual appliances were as follows: less appliance
Discussion.—Most of the trials evaluated are small, nonrandomized, and cover only short-term adverse effects.
332
Dental Abstracts