Quality assessment of online information on orthodontic Web sites in the United States.

INTRODUCTION: The objective of this study was to assess the quality of online information on orthodontic treatment provided by orthodontic Web sites in the United States and investigate their claims. METHODS: Three hundred and one American orthodontic Web sites were identified after an advanced Google search. Data collection included: the location of the clinic, treatment options offered, quality-of-information assessment using the DISCERN tool, and finally, claims when promoting 1 treatment option against another, as well as the presence of information on relapse risk and retention needs. RESULTS: All Web sites belonged to private clinics, with more than half (60.5%) in a single location. Invisalign (Align Technology, Santa Clara, Calif) was the most commonly promoted treatment option (94%), followed by the full fixed appliance (FFA) (92%). The mean DISCERN total score was poor (36.78 out of 80.00), whereas the mean reliability (questions 1-8) and quality-of-information (questions 9-15) scores were 17.06 out of 40.00 and 16.85 out of 35.00, respectively. Almost one-third (28%) of the Web sites compared aligners to FFA, whereas 25% claimed that aligners are less painful than FFA, faster than FFA (14%), or give better results than FFA (1%). Almost half of the Web sites (47%) failed to display information on relapse risk and retention needs after orthodontic treatment (41%). The Web sites that displayed such info had higher DISCERN total scores (P <0.001). CONCLUSIONS: Invisalign seems to be the treatment modality most commonly mentioned online. According to DISCERN, U.S. orthodontic Web sites display poor or fair quality information. On many Web sites, aligner treatment was compared with FFA, with some stating that aligners cause less pain than FFA or are more efficient/faster than FFA. Moreover, almost half of the American orthodontic Web sites failed to display information on the relapse risk or retention need. Display of such information can be an indicator of better-quality Web sites. There is ample room for improvement in the online information American orthodontists provide to potential patients.

Cantilevers: Multi-Tool in Orthodontic Treatment.

This review aims to discuss and illustrate various uses of cantilevers to solve multiple clinical issues and prove their versatility. Cantilevers are commonly used in the segmented arch technique, and they can be designed to solve various clinical problems with highly predictable results. Its design and shape can modify the various combinations of vertical and horizontal forces. The novel trend is to combine cantilevers with skeletal anchorage. Cantilevers offer a very simple and statically determined force system. The advantage is the control over side effects, which normally occur on the anchor teeth and the occlusion. The disadvantages include possible side effects on the anchorage unit, when the anchorage is poorly controlled. The review highlights the clear benefits of cantilever use in complex corrections of single teeth, segments, and entire arch with a diminished effect on the dentition, also with the use of skeletal anchorage. With their simple and easily tailored design, these springs can be called an orthodontic multi-tool.

Standardizing Terminology and Assessment for Orofacial Conditions in Juvenile Idiopathic Arthritis: International, Multidisciplinary Consensus-based Recommendations.

OBJECTIVE: To propose multidisciplinary, consensus-based, standardization of operational terminology and method of assessment for temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA). METHODS: Using a sequential expert group-defined terminology and methods-of-assessment approach by (1) establishment of task force, (2) item generation, (3) working group consensus, (4) external expert content validity testing, and (5) multidisciplinary group of experts final Delphi survey consensus. RESULTS: Seven standardized operational terms were defined: TMJ arthritis, TMJ involvement, TMJ arthritis management, dentofacial deformity, TMJ deformity, TMJ symptoms, and TMJ dysfunction. CONCLUSION: Definition of 7 operational standardized terms provides an optimal platform for communication across healthcare providers involved in JIA-TMJ arthritis management.

Evaluation of facial asymmetry in patients with juvenile idiopathic arthritis: Correlation between hard tissue and soft tissue landmarks.

INTRODUCTION: The aims of this study were to assess the correlation between facial hard and soft tissue asymmetry in patients with juvenile idiopathic arthritis, to identify valid soft tissue points for clinical examination, and to assess the smallest clinically detectable level of dentofacial asymmetry. METHODS: Full-face cone-beam computed tomography scans and 3-dimensional photographs were used to assess facial hard and soft tissue asymmetry in 21 patients with juvenile idiopathic arthritis. A survey was conducted to assess how asymmetry is perceived observationally based on cone-beam computed tomography scans and 3-dimensional photographs. RESULTS: Significant linear correlations were seen between the hard and soft tissue landmark deviations at both the transverse and vertical positions. Among medial soft tissue points, glabella had the smallest deviation and pogonion the largest deviation from the midsagittal plane. Professionals could identify facial asymmetry based on images beyond a cutoff threshold of 2 mm for both pogonion and gonion. CONCLUSIONS: Soft tissue pogonion and gonion were identified as the most appropriate landmarks to clinically predict hard tissue facial asymmetry. Facial asymmetries are most pronounced in the lower facial third in patients with juvenile idiopathic arthritis. Professionals can accurately identify asymmetry exceeding 2 mm.

The effect of biologic factors and adjunctive therapies on orthodontically induced inflammatory root resorption: a systematic review and meta-analysis.

Objective: Biologic factors and adjunctive therapies are known to affect the degree of orthodontically induced inflammatory root resorption (OIIRR). However, a systematic overall assessment of their impact on OIIRR has not previously been reported. We, therefore, aimed to systematically assess effects on OIIRR of biologic factors and adjunctive therapies in human and animal subjects. Methods: A comprehensive search strategy was performed for all major electronic databases. Two reviewers independently selected studies, undertook data extraction and assessed the risk of bias for all included studies according to a pre-specified protocol inspired by Cochrane and the PRISMA guidelines. Eligible studies compared the effect of intervention(s) in an experimental and a control group. Results: A total of 9 human and 36 animal trials met the inclusion criteria. Where appropriate, random-effect meta-analyses were carried out to determine the outcome measure OIIRR. The random-effect meta-analysis demonstrated that OIIRR was inhibited by fluoride (ES = -2.08 [-3.02, -1.14]), thyroxine (ES = -1.91 [-3.20, -0.61]), and steroids (ES = -2.79 [-4.26, -1.33]). In contrast, corticotomy (ES = 0.38 [0.05, 0.71]) significantly enhanced OIIRR. Conclusion: In animals, administration of fluoride, thyroxine and steroids decreased OIIRR, whereas corticotomy increased OIIRR. In general, the effect on OIIRR increased with higher dosage and/or exposure time. Despite methodological limitations of the included studies, this systematic review provides an important overview of the effect of biologic factors and adjunctive therapies on OIIRR.

Assessment of dentofacial growth deviation in juvenile idiopathic arthritis: Reliability and validity of three-dimensional morphometric measures.

INTRODUCTION: Patients with juvenile idiopathic arthritis (JIA) and involvement of the temporomandibular joint (TMJ) often experience abnormal facial growth. Three-dimensional (3D) assessment of dentofacial growth deviation has become more common with advancement and commercialization of imaging technologies. However, no standardized guidelines exist for interpretation of 3D imaging in patients with JIA. The aim of this study was to propose and validate morphometric measures for the 3D radiographic assessment of dentofacial growth deviation in patients with JIA to enhance: 1) Description of dentofacial growth deviation; 2) Treatment planning; 3) Longitudinal follow-up. METHODS: The study was conducted in a standardized sequential-phased approach involving: 1) Preliminary decision-making; 2) Item generation; 3) Test of content-validity; 4) Test of reliability; 5) Test of construct validity; 6) Establishment of final recommendations. RESULTS: Twenty-one morphometric measures were evaluated. Based on results of reliability and validity-testing including subjects with JIA (n = 70) and non-JIA controls (n = 19), seven measures received a "high recommendation" score. Those measures were associated with posterior mandibular height, occlusal cant, mandibular asymmetry, mandibular inclination, and anterior/posterior lower face height. Nine other measures were "moderately recommended" and five received a "somewhat recommendation" score. CONCLUSION: Seven morphometric measures were considered very useful in the 3D assessment of growth deviation in patients with TMJ disease associated with JIA. These variables can be used to standardize the description of dentofacial deformities and to plan corrective interventions.

No association between types of unilateral mandibular condylar abnormalities and facial asymmetry in orthopedic-treated patients with juvenile idiopathic arthritis.

INTRODUCTION: Dentofacial asymmetries are often observed in patients with juvenile idiopathic arthritis (JIA) and temporomandibular joint (TMJ) involvements. The aim of this split-face study was to associate types of radiologic TMJ abnormalities with the degree of dentofacial asymmetry in patients with unilateral TMJ involvements assessed with cone-beam computed tomography. METHODS: Forty-seven JIA patients and 19 nonarthritic control subjects were included in the study. Normal condylar radiologic cone-beam computed tomography appearance in at least 1 TMJ was the inclusion criterion for all patients with JIA. The contralateral TMJ was thereafter scored as either "normal," "deformed," or "erosive," consistent with predefined criteria. Based on the bilateral radiologic TMJ appearances, 3 JIA groups were assigned: normal/normal, normal/deformed, and normal/erosive. The severity of the dentofacial asymmetry was compared between the JIA groups and control subjects. Dentofacial asymmetry was expressed as interside ratios and angular measurements. RESULTS: Eighty-seven percent of the JIA patients were being treated or had previously received treatment with a functional orthopedic appliance at the time of the cone-beam computed tomography. Significantly greater dentofacial asymmetries were observed in the 2 groups of JIA patients with unilateral condylar abnormalities (deformation or erosion) than in the other groups. A similar degree of dentofacial asymmetry was observed in JIA patients with bilateral normal TMJs and in the nonarthritic control group. CONCLUSIONS: JIA patients with unilateral condylar abnormalities (deformation or erosion) exhibited significantly more severe dentofacial asymmetries than did the JIA patients without condylar abnormalities and the control subjects. We found the same degree of dentofacial asymmetry when dividing patients with condylar abnormalities into deformation and erosion groups.

Idiopathic condylar resorptions: 3-dimensional condylar bony deformation, signs and symptoms.

INTRODUCTION: Our aim was to describe 3-dimensional condylar deformation of the temporomandibular joint (TMJ) and symptoms and signs of temporomandibular dysfunction (TMD) in patients with idiopathic condylar resorption (ICR). METHODS: We included 25 patients with ICR and 25 controls. We performed cone-beam computed tomographic scans and analyzed condylar width, length, and height as well as the condylar axial angle and the condylar neck angle. TMJ cross sections were evaluated for degenerative characteristics and location of bony deformations. Furthermore, symptoms and signs of TMD were described in the ICR group. RESULTS: In the ICR group, we found statistically significantly reduced condylar width (mean difference, 2.0 mm), height (mean difference, 4.9 mm), and condylar axial angle (mean difference, 10.6°); 84% of the TMJs had a posterior condylar neck angle (control group, 22%). The most common degenerative changes were noncongruent shape of the condyle-fossa relationship (72%), condylar resorption (56%), and nonintact cortex (40%). More than 70% of the joints with bony deformations showed changes along the entire condylar head. Most patients with ICR showed symptoms and signs of TMD; nevertheless, 12% had no signs or symptoms of TMD. CONCLUSIONS: ICR in the TMJ changes the shape and reduces the size of the condyle. Deformity locations are unspecified, and the entire condyle is often affected. Most patients with ICR have signs or symptoms of TMD; however, a small group was asymptomatic and without clinical signs.

Clinical Orofacial Examination in Juvenile Idiopathic Arthritis: International Consensus-based Recommendations for Monitoring Patients in Clinical Practice and Research Studies.

OBJECTIVE: To develop international consensus-based recommendations for the orofacial examination of patients with juvenile idiopathic arthritis (JIA), for use in clinical practice and research. METHODS: Using a sequential phased approach, a multidisciplinary task force developed and evaluated a set of recommendations for the orofacial examination of patients with JIA. Phase 1: A Delphi survey was conducted among 40 expert physicians and dentists with the aim of identifying and ranking the importance of items for inclusion. Phase 2: The task force developed consensus about the domains and items to be included in the recommendations. Phase 3: A systematic literature review was performed to assess the evidence supporting the consensus-based recommendations. Phase 4: An independent group of orofacial and JIA experts were invited to assess the content validity of the task force's recommendations. RESULTS: Five recommendations were developed to assess the following 5 domains: medical history, orofacial symptoms, muscle and temporomandibular joint function, orofacial function, and dentofacial growth. After application of data search criteria, 56 articles were included in the systematic review. The level of evidence for the 5 recommendations was derived primarily from descriptive studies, such as cross-sectional and case-control studies. CONCLUSION: Five recommendations are proposed for the orofacial examination of patients with JIA to improve the clinical practice and aid standardized data collection for future studies. The task force has formulated a future research program based on the proposed recommendations.

Clinical predictors of temporomandibular joint arthritis in juvenile idiopathic arthritis: A systematic literature review.

AIM: To assess the level of evidence for subjective and objective parameters in clinical orofacial examination and determine if predictors for temporomandibular joint (TMJ) involvement in juvenile idiopathic arthritis (JIA) patients exist in the current literature. METHOD: A comprehensive systematic electronic search strategy was performed in all major medical databases in June 2015. Studies were selected independently by two reviewers in accordance with a prespecified protocol and a risk of bias assessment for all included studies. Subjective examination outcome measures assessed were pain, decreased TMJ function, and TMJ sounds. The objective outcome measures assessed were maximal incisor opening, mandibular asymmetric opening, condylar translation, protrusion, myofascial pain on palpation, facial asymmetry, and micro- or retrognathism. RESULTS: The electronic database search identified 345 unique citations. After application of our strict, predefined inclusion and exclusion criteria, 21 articles were included and data extracted. The study heterogeneity did not allow for meta-analyses. No singular outcome measure can be suggested as a predictor of TMJ involvement in JIA, as sensitivity and/or specificity is too low compared to contrast-enhanced magnetic resonance imaging. CONCLUSION: The current low level of evidence and study heterogeneity do not allow us to conclude on singular clinical outcome measures. To increase study comparability, we call for a standardized terminology and evidence-based guidelines for clinical orofacial examination parameters in JIA patients.

Temporomandibular joint steroid injections in patients with juvenile idiopathic arthritis: an observational pilot study on the long-term effect on signs and symptoms.

BACKGROUND: Temporomandibular joint (TMJ) inflammation in patients with juvenile idiopathic arthritis (JIA) can lead to orofacial pain and malfunction of the TMJ. Intra-articular corticosteroid injections (IACI) have been suggested as a treatment modality against TMJ arthritis-related orofacial signs and symptoms. However, knowledge of the effect-durability of these injections remains unanswered. The aim of this pilot study was to evaluate the short and long-term effects of IACI on orofacial symptoms in a prospective observational study based on pre-specified clinical examination standards. METHODS: Thirteen patients with JIA and arthritis-related orofacial signs and symptoms were included in this prospective pilot study (median 17.2 years, IQR 15-18.4 years). All patients received TMJ IACI (11 bilateral and two unilateral) due to an insufficient response to previous pain-management treatments. Three standardized clinical examinations were carried out: T1 prior to treatment, T2 short-term follow-up (mean 34 days post-treatment), T3 long-term follow-up (mean 333 days post-treatment). RESULTS: Significant pain reduction was observed at the short-term follow-up (T2). Resolution of orofacial pain after IACI was a rare finding at T2. Generally, the pain significantly worsened between T2 and T3 examinations. The reported pain levels rose between T2 and T3 indicating a loss of effect of the IACI at the long-term follow-up examination (T3). Non-significant improvements in TMJ mobility were observed at T2 and T3. CONCLUSION: Our results suggest a palliative (not curative) effect of IACI for TMJ arthritis-related orofacial symptoms in patients with long-term orofacial pain complaints. The short-term improvements in signs and symptoms were partly resolved at the long-term follow-up.

Signs and symptoms after temporomandibular joint washing and cannula placement assessed by cone beam computerized tomography.

OBJECTIVE: Analyses of temporomandibular joint synovial fluid using the hydroxocobalamin push-pull technique are increasingly used. However, objective complications and subjective experiences from this procedure have not been described. Firstly, this study aimed to describe discomfort and potential side-effects of this method with special emphasis on symptoms related to the arthrocentesis to be used for future patient information and Ethical Committee applications. Secondly, this study aimed to evaluate the use of cone beam computed tomography (CBCT) as control of intra-capsular cannula placement. METHODS: Twenty healthy, young adult volunteers were included. Extensive objective and subjective questionnaires were completed before and 14 days after the synovial fluid sampling. With the cannula inside the joints a CBCT was done to investigate if this procedure can be used to verify intra-capsular cannula position. RESULTS: The subjective findings: Most subjects did experience mild pain or discomfort post-operatively. In 12 of 20 subjects symptoms had resolved after 2 days and no subjects had symptoms for more than a week. The longer lasting symptoms were mainly transient joint sounds on mandibular movement. Objective findings: 14 days after the sampling mandibular protrusion had improved 1 mm, but all other objective measures were equal compared to baseline. CBCT showed a large variation in cannula position and no conclusions could be drawn from this. CONCLUSION: The hydroxocobalamin push-pull synovial fluid sampling may cause minor, transient symptoms. CBCT does not seem to provide any clinical benefits concerning the correct cannula position in relation to the upper joint compartment and disc.

Quantitative histological changes of repeated antigen-induced arthritis in the temporomandibular joints of rabbits treated with intra-articular corticosteroid.

BACKGROUND: To compare the inflammatory changes of antigen-induced temporomandibular joint (TMJ) arthritis in rabbits by different histological methods and to evaluate the immunomodulatory effect of intra-articular corticosteroid injections histologically. METHODS: 35 rabbits (10 weeks old) pre-sensibilized with ovalbumin were divided into three groups: a placebo group of five (saline), an arthritis group of 15 (ovalbumin) and a steroid-treated group of 15 (ovalbumin + corticosteroid). Additionally, a group of seven rabbits receiving no sensibilization with ovalbumin and no intra-articular injections served as controls. Histomorphometry of the inflammatory changes in the subsynovial connective tissue (SSCT) of the TMJ included: (i) semi-quantitative (S-Q) scoring of inflammation and synovial proliferation, (ii) thickness measurements and fractional surface and (iii) stereological quantitative assessment of volume and plasma cells in thick sections of the SSCT by an optical fractionator. RESULTS: The histomorphometry showed synovial proliferation in both the arthritis and the steroid groups. The plasma cell count obtained by the optical fractionator was significantly reduced when treating the TMJ with corticosteroids. However, the thickness of the synovial lining and volume of the SSCT as well as S-Q scoring of inflammation showed no difference between the arthritis and the steroid-treated groups. The optical fractionator proved a superior tool compared to S-Q assessments. CONCLUSION: Counting of plasma cells in the SSCT showed that corticosteroids reduced the inflammation, but did not eliminate it. Semiquantitative scoring of synovial proliferation and inflammation demonstrated low sensitivity regarding changes in immunomodulation in antigen-induced arthritis compared to stereological quantitative estimations using an optical fractionator.