Orthodontic Retention – what really works?

A rare clinical topic but with a business twist – the patient wants stability and clear direction as to how that will be maintained, if it doesn’t work they’re unhappy and you are duty bound to repeat the treatment without a fee.

I spent time as an Orthodontic clinical assistant in Gloucestershire Royal, I worked, happily, as a locum in an Ortho practice and I also found myself at one time the partner in an Orthodontic practice – a long story.

During all of this there were certain things that were not clear, and never became clear, and on which, people had dogmatic and, often, opposing opinions.

The main one of these was retention. During my years as a generalist with a particular emphasis and interest in treating children one of the difficult questions I faced from the 16-21 group was, “I had my braces off x years ago but my teeth have all moved again, what can I do?” of course I heard that as, “what will you do?”

I know this was widespread and “redoing the front 6” has formed the basis of the boom in short term orthodontics. Disappointed patients, especially when they were first treated on the NHS and now are asked to pay, isn’t great for the image of dentistry. The possibility of a second failure due to relapse is even worse and possibly adds to the rise in orthodontic claims and complaints.

But what is best? Fixed retainers, Hawleys, Essix – frankly I was never sure and am still not. My “purely as a layman” advice these days is, “ah yes your dentist has fitted a fixed retainer, that’s good but personally I think you should keep wearing your plastic retainers at least once a week for ever.”

So I was interested in Kevin O’Briens orthodontic blog, “What do we know about orthodontic retention? A new Cochrane Review tells us something?”

Here’s a link to the post.

I’m not sure that I’m so keen on his own conclusion.

This is a Cochrane review and the findings are of high quality. One of their conclusions was that most of the studies they included were of high risk of bias. However, one of the concerns that I have with the Cochrane risk of bias assessment is that it is very unforgiving and when I looked at the reason for the classification of some of the studies, I felt that this was rather harsh. As a result, it is important to evaluate the risk of bias tables in these reviews and come to your own decisions on whether findings are going to influence your practice.

So, how does this review influence my practice. In previous postings I have emphasised that when we evaluate a study we need to look closely at the treatment effect. I have looked closely at the differences that they calculated for this review and all these are very small. As a result, I cannot help feeling that when we look at the effectiveness of the different regimes they all seem to “work”.  It is also important to point out that the most important factor in retention is patient co-operation and I presume that the trials included this as an outcome, but I could not find any detailed information.

My next step was to look at patient preferences and acceptability The analysis showed that patients tended to prefer bonded retainers. So at this point I am beginning to think that bonded retainers are the best? But I really do not like them because of hassle with failures. I was, therefore, surprised to see that they reported low failure rates.

I was in a dilemma and I wondered how I could practice evidence based orthodontic retention. But I got round this by considering that evidence based care is built around a combination of scientific evidence, clinical experience and patient opinion. If we factor this in, I can conclude the following:

– The research evidence shows that it all works.
– My clinical experience of bonded retainers is not good, I get too many debonds.
– Patients like thermoplastic retainers and they can be worn part time.

As a result, I am going to stick with thermoplastic retainers which are worn at night only.

Or…have I dodged the issue?

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