Increasing the Value of Orthodontic Research Through the Use of Dental Patient-Reported Outcomes

doi:10.1016/j.jebdp.2019.04.005

Journal of Evidence Based Dental Practice

Volume 19, Issue 2, June 2019, Pages 99-105

https://doi.org/10.1016/j.jebdp.2019.04.005 Get rights and content

Abstract

Ten years ago, Chalmers and Glasziou pointed out in the Lancet that 85% of all biomedical research was being avoidably wasted because of imbalanced research question/outcome selection, as well as poor study design, execution, and reporting. According to findings of recent “research on research” studies, a high level of such kind of avoidable waste should also exist in orthodontic research. This warrants efforts to improve each stage of the research production and reporting process.

Nowadays, patients' psychosocial function is considered a core element of oral health. Also, their treatment needs and preferences have formed a main component of evidence-based dentistry. Therefore, to achieve shared decision-making, orthodontists need to have an adequate understanding of each patient's values and perceptions.

In this context, orthodontic research should be patient-centered so that the knowledge and perception gaps between clinicians and patients can be reduced, and research evidence that is suitable for patients to understand can be provided. In addition, patient-centered outcomes that can reflect patients' perceptions and psychosocial status should be widely used.

However, recent scoping reviews have shown that during the past decade, patient-centered outcomes including those regarding adverse effects, health service resource utilization, and quality of life have remained under-represented in orthodontic trials. Thus, the use of dental patient-reported outcomes and dental patient-reported outcome measures should be promoted to facilitate the provision of a patient-centered evidence base, reduce the avoidable waste related to research question/outcome selection, and thereby increase the value of orthodontic research.

Section snippets

Avoidable Waste in Orthodontic Research

Just ten years ago, Chalmers and Glasziou¹ pointed out in the Lancet that a majority of all biomedical research was being avoidably wasted because of imbalanced research question/outcome selection, inadequate study design and execution, nonpublication, lack of accessibility, and poor reporting. Because more than 50% of studies failed to take adequate steps to reduce biases (eg, inadequate allocation concealment),² more than 50% of studies were never published in full,³ and more than 50% of

Patients' Perceptions and the Definition of Oral Health

Recognition of the importance of patients' perception can be traced back to the addition of “social well-being” into the World Health Organization definition of health in 1940s, which led to a paradigm shift in the model of health from biomedical to biopsychosocial.¹² Thereafter, similar modifications were made to the definition of oral health. In 1993, Dolan¹³ defined oral health (for older populations) as “a comfortable and functional dentition which allows individuals to continue in their

Evidence-Based Medicine and Evidence-Based Dentistry

A common criticism of evidence-based medicine (EBM) has been that EBM means “cookbook medicine” and decision-making based on evidence alone, without necessary deliberation and reasoning.¹⁵ However, as experts in EBM¹⁶ and evidence-based orthodontics¹⁷ have pointed out, such an argument is merely a misunderstanding of what EBM is. In effect, the need to consider each patient's values has been aggressively promoted since the very early years of EBM.¹⁶

In 1996, Sacket et al. ¹⁸ already stated,

“EBM

SDM in Orthodontic Practice

According to Gatellari et al,²³ SDM is a decision-making process in which clinicians and patients are equal partners and are required to exchange information and preferences to negotiate a mutually acceptable treatment decision. In the case of orthodontics, this approach is particularly important for many reasons. Some of the main ones are as follows.

First, as malocclusion is not a disease but a variation from the societal norm,²⁴ orthodontic treatment is often elective.²⁵ In addition,

Patient-Centered Research and Patient-Centered Outcomes

The ultimate goal of all medical research is to improve our knowledge underpinning the prevention and treatment of illness.³⁴ In the context of EBD, dental studies should be designed, executed, and reported properly so that their findings are relevant, valid, and useable, facilitating the achievement and development of patient-centered, evidence-based dental practice. Toward this end, the research questions of dental studies should be relevant to patients, and the outcomes that they use should

dPROs and dPROMs

dPROs, a term recently coined by John,⁴⁰ are defined as “any report of the status of a patient's oral health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else.” Similar to oral health being a component of general health, dPROs are a subset of all patient-reported outcomes (PROs). dPROs can capture the impact of conditions or interventions on oral health, while dental dPROMs are used to assess this impact and express it

OHRQoL and Orthodontic Research

As mentioned previously, OHRQoL is a major dPRO, and each OHRQoL instrument can be seen as a dPROM or a combination of several dPROMs (depending on the number of dimensions the instrument contains).⁴¹ During the past twenty years, orthodontic researchers have carried out many epidemiological studies regarding OHRQoL.⁴⁵ Based on these, recent systematic reviews have concluded that malocclusion has a significant (although small) negative impact on the OHRQoL of children (mainly in the emotional

Summary

Patients' psychosocial function is a core element of oral health; their treatment needs and preferences form a main component of EBD. However, recent studies have shown that most of the outcomes measured in orthodontic trials are focused on assessing morphologic changes, whereas patient-centered outcomes have remained under-represented. In light of this, the use of dPROs and dPROMs should be promoted to facilitate the provision of a patient-centered evidence base, reduce the avoidable waste

Acknowledgments

F.H. is supported by the China Postdoctoral Science Foundation (No. 2018M630884).

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Cited by (58)

Enhancing the quality of reporting of orthodontic clinical research
2024, Seminars in Orthodontics
Research reports need to provide complete, accurate, and transparent information to allow readers to easily understand and critically assess the study results. Poor reporting makes studies unable to be synthesized in systematic reviews, fail to inform clinical practice, and compromise evidence-based clinical decision making. Evidence suggested the reporting quality of orthodontic clinical studies was poor, which caused a large amount of avoidable research waste. Reporting guidelines (RGs) are developed to guide and standardize the reporting of specific study types and improve their reporting quality. This article introduces the commonly used RGs in orthodontic clinical studies and illustrates the relationship between the existing RGs and their extensions. The majority of extensions are those to the CONSORT and PRISMA guidelines. The EQUATOR Network is an online library of RGs and education resources, and authors can use it to find appropriate RGs. Although a large number of RGs and extensions have been published, involving various study types, the reporting quality of orthodontic clinical studies still needs to be improved. Active strategies to strengthen the implementation of RGs are necessary to fill the gaps between RG publication and the quality improvement of studies. Other issues including selective reporting and spin, structure format of abstracts, and artificial intelligence in reporting are also discussed. Language models such as ChatGPT have largely changed scientific research and reporting in the era of artificial intelligence. Authors are strongly recommended to always be transparent in reporting and responsible for the content of their studies.
DENTAL PATIENT-REPORTED OUTCOMES UPDATE 2023
2024, Journal of Evidence-Based Dental Practice
The emergence and rapid development of disruptive innovations are quickly turning our profession into personalized dentistry, built upon evidence-based, data-oriented, and patient-centered research. In order to help improve the quality and quantity of patient-centered evidence in dentistry, further promote the wide and standard use of dental patient-reported outcomes (dPROs) and dental patient-reported outcome measures (dPROMs), the Journal of Evidence-Based Dental Practice has put together this special issue, the third of a series entitled Dental Patient-Reported Outcomes Update.
A total of 7 solicited articles are collected in this issue. To put them into a broader perspective, this review provides a concise summary of key, selected PRO and dPRO articles published during 2023. A brief introduction to those articles included in this Special Issue follows. Four main domains are covered in this Special Issue: (1) dPROs and digital dentistry, (2) standardization of dPRO-related methodology, (3) current usage of dPROs and dPROMs in published research, and (iv) the significance and relevance of dPRO usage.
THE USE OF DENTAL PATIENT-REPORTED OUTCOMES AMONG COMPARATIVE OBSERVATIONAL STUDIES IN ORTHODONTICS: A METHODOLOGICAL STUDY
2024, Journal of Evidence-Based Dental Practice
To identify and summarize the presence and characteristics of dental patient-reported outcomes (dPROs) and dental patient-reported outcome measures (dPROMs) within comparative observational studies published in 5 leading orthodontic journals.
Electronic searching was performed to identify intervention (therapeutic or preventive) related comparative observational studies published in selected journals between 2015 and 2021. Two authors extracted the characteristics of each included study independently and in duplicate and summarized the dPROs and dPROMs used in these studies. All dPROs were classified into 2 general types (oral health-related quality of life [OHRQoL] and others), while dPROMs were divided into 3 categories (single-item questionnaires, generic multiple-item questionnaires, and specific multiple-item questionnaires). In addition, dPROMs were examined, if they evaluated the 4 dimensions of OHRQoL (oral function, orofacial pain, orofacial appearance, and psychosocial impact).
A total of 683 observational studies were eligible and included of which 117 (17.1%) used dPROs and dPROMs. Seven different dPROs (OHRQoL, patients’ satisfaction with treatment, preferences, concerns, compliance, duration, and unwanted events) and 33 different dPROMs (including 8 single-item questionnaires, 11 generic multiple-item questionnaires, and 14 specific multiple-item questionnaires) were identified in these studies. OHRQoL was the most commonly used dPRO (92/117, 78.6%), while Oral Health Impact Profile 14 (OHIP-14) was the most frequently used dPROM (20/92, 21.7%). In terms of study design, cross-sectional studies had the highest proportion of dPRO usage (62/148, 41.9%), followed by cohort studies (63/505, 12.5%) and case-control studies (1/30, 3.3%).
Only one-sixth of comparative observational studies published in leading orthodontic journals could reflect patients’ perspectives. Observational studies in orthodontics need to provide more patient-important information through the use of dPROs and dPROMs.
GLOSSARY FOR DENTAL PATIENT-CENTERED OUTCOMES
2024, Journal of Evidence-Based Dental Practice
Dental patient-centered outcomes can improve the relevance of clinical study results to dental patients and generate evidence to optimize health outcomes for dental patients. Dental patient-reported outcomes (dPROs) are of great importance to patient-centered dental care. They can be used to evaluate the health outcomes of an individual patient about the impact of oral diseases and treatment, and to assess the quality of oral health care delivery for a health care entity. dPROs are measured with dental patient-reported outcome measures (dPROMs). dPROMs should be validated and tested before wider dissemination and application to ensure that they can accurately capture the intended dPROs. Evidence suggests inadequate dPRO usage among dental trials, as well as potential flaws in some existing dPROMs. This Glossary presents a collection of main terms in dental patient-centered outcomes to help clinicians and researchers read and understand patient-centered clinical studies in dentistry.
The oral health impact of dental hygiene and dental therapy populations: a systematic review
2024, Journal of Evidence-Based Dental Practice
Oral health-related quality of life (OHRQoL) is pivotal in patient care, reflecting oral health through dental patient-reported outcomes (dPROs). This systematic review aims to outline the 4-dimensional (4-D) impact of OHRQoL within patient populations routinely treated by dental hygiene and/or dental therapy providers, as there is limited literature present for these oral health care professionals.
The study extracted and analyzed characteristics and multidimensional impact of OHRQoL, using the Oral Health Impact Profile (OHIP) as the primary dental patient-reported outcome measure (dPROM). The search strategy spanned 7 databases: Medline via the Ovid interface (Ovid MEDLINE(R) ALL), Embase via Ovid, Cinahl, APA PsycINFO via Ovid, Dentistry and Oral Sciences Search, Scopus, and Web of Science (Core Collection). It commenced September 2, 2022, with a refinement search on July 5, 2023. English language criteria yielded 645 articles postduplication removal. A screening procedure involving 3 reviewers encompassed title, abstract, and full-text review.
After application of inclusion and exclusion criteria, 5 articles were subjected to data extraction, capturing domain-specific information including baseline and follow-up OHRQoL data. An additional set of 13 articles containing summarized OHRQoL data underwent separate analysis. The Joanna Briggs Institute (JBI) critical appraisal tools were utilized for risk bias assessment of the included articles. The 4-D impact scores reported for baseline OHRQoL data, ranged from 3.10 to 4.20 for Oral Function, 0.84-2.70 for Orofacial Pain, 1.70-4.50 for Orofacial Appearance, and 0.44-2.50 for Psychosocial Impact. In follow-up OHRQoL data, the range for Oral Function was 1.52-3.60, Orofacial Pain 0.60-2.10, Orofacial Appearance 0.91-2.25, and Psychosocial Impact 0.10-0.60.
This review highlights a critical call for standardization in OHRQoL data collection for dental hygiene and dental therapy patient populations as only 26% of the predetermined distinct populations were found to have studies completed with 4-D impact of OHRQoL. Moreover, the presence of limited research in describing the multi-dimensional impact in patients routinely treated by these providers shows the urgency of substantive research in this area.
THE CONTENTS, METHODS, AND ASSESSMENT OF EVIDENCE-BASED DENTISTRY EDUCATION: A SCOPING REVIEW
2023, Journal of Evidence-Based Dental Practice
With evidence-based dentistry (EBD) having a far-reaching influence on oral healthcare, dental educators worldwide have made joint efforts to integrate EBD-related knowledge and skills into dental education. The present scoping review aims to identify and summarize the existing teaching contents, teaching methods, and assessment strategies of EBD education.
Electronic (PubMed and Embase) and manual searches were performed to identify articles related to both “dental education” and “evidence-based practice.” Based on predetermined eligibility criteria, articles were selected by 2 reviewers, independently and in duplicate. Data synthesis was conducted based on teaching contents, teaching strategies, and teaching assessment.
Of the 1758 articles found in the literature searches, 74 were deemed eligible and included in this review. A total of 4 basic skills (problem formulation, literature searching, critical appraisal, and research methodology), 5 teaching methods, and 6 assessment strategies were identified. In most of the articles, 2, or more skills were taught, and a combination of traditional strategies for teaching and its assessment (eg, courses and questionnaire survey) was involved. Other teaching methods, such as journal clubs and workshops, were seldom used, and validated assessment tools accounted for a relatively small proportion of the assessment strategies involved.
The contents, methods and assessment of EBD education have been widely studied and discussed. However, the current literature focuses mainly on teaching of critical appraisal skills, traditional teaching methods, and short-term outcome assessments. Future research in this area can be aimed at integrating all EBD-related skills into educational models, studying multifaceted teaching approaches, and developing comprehensive teaching outcome assessment methods based on validated tools and dental patient-reported outcomes.

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EditorialIncreasing the Value of Orthodontic Research Through the Use of Dental Patient-Reported Outcomes

Abstract

Section snippets

Avoidable Waste in Orthodontic Research

Patients' Perceptions and the Definition of Oral Health

Evidence-Based Medicine and Evidence-Based Dentistry

SDM in Orthodontic Practice

Patient-Centered Research and Patient-Centered Outcomes

dPROs and dPROMs

OHRQoL and Orthodontic Research

Summary

Acknowledgments

Lancet

Lancet

Lancet

Am J Orthod Dentofacial Orthop

J Dent

J Am Dent Assoc

Lancet

Am J Orthod Dentofacial Orthop

J Evid Based Dent Pract

J Am Dent Assoc

Am J Orthod Dentofacial Orthop

Soc Sci Med

Saudi Dent J

Am J Orthod Dentofacial Orthop

J Evid Based Dent Pract

J Am Dent Assoc

J Dent

Am J Orthod Dentofacial Orthop

Semin Orthod

J Evid Based Dent Pract

J Evid Based Dent Pract

J Dent

J Evid Based Dent Pract

Am J Orthod Dentofacial Orthop

Adequacy and reporting of allocation concealment: review of recent trials published in four general medical journals

BMJ

Full publication of results initially presented in abstracts

Cochrane Database Syst Rev

Editorial
Increasing the Value of Orthodontic Research Through the Use of Dental Patient-Reported Outcomes