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HERRERA ET AL .
(Continued) PICOS question addressed by a SR
Balance of benefit and harm In stage IV periodontitis patients in need of OT, the benefit after OT clearly outweighs the harm since the overall pooled effect resulted in a beneficial impact on CAL, PPD, RBL and gingival inflammation without being associated with significant adverse or secondary effects.
R7.4: Expert consensus-based statement Grade of recommendation GradeO — $ Strength of consensus Strong consensus (0% of the group abstained due to potential CoI)
From evidence to recommendation — additional considerations
Background
Intervention
Acceptability The addition of OT might impose an additional burden in patients, but the expected benefits resulting from the improved function and aes- thetics are usually understood and well accepted by the affected patients, although there is lack of evidence on PROMs from the referred studies. Feasibility, ethical and economic considerations These combined treatments need the collective effort of many oral health providers (dental hygienists, periodontists, orthodontists or dentists with advanced training and skills) since beyond the manage- ment of the OT, patient's oral hygiene and periodontal status must be carefully monitored throughout the treatment. Availability of these needed human resources vary widely depending on the envi- ronment and may be influenced by the available public healthcare funding, since in many instances it must be self-funded by the affected patient, what may implicate inequalities in the access to these treatments. There is no evidence on the economic effects, since there are no cost-effectiveness studies, although these com- bined periodontal/orthodontic treatments are usually costly since they require complex interventions and require multiple care providers.
Tilted molars are a frequent sequela of tooth loss and periodontal attachment loss in stage IV periodontitis patients, often in combina- tion with bite collapse and loss of the vertical dimension of the occlu- sion. The treatment of these sequelae usually involves OT using movements of tooth up-righting, which may cause adverse effects to the affected teeth (further attachment and/or bone loss).
Available evidence
Number and design of included studies The SR by Kloukos et al. (2021) has only identified one study evaluat- ing the effect of OT on tilted molars (Kraal et al., 1980). This split- mouth retrospective study reported a single cohort of patients, where, on one side, tilted molars were orthodontically treated, while, on the contra-lateral side, they were not. Risk of bias Using the ROBINS-I-tool, this study by Kraal et al. (1980) was rated as of critical risk of bias. Effect sizes and their clinical relevance There were no data available on PPD or CAL changes. Results only reported mean radiographic bone height changes. In 15 patients with treated and untreated sides, mean bone height change was 2.21mm (SD = 4.53) in untreated, versus 1.07mm SD = 7.35) in treated teeth. The mean bone height change was 2.53mm (SD = 4.53) in 15 untreated molars, versus 1.60mm (SD = 7.01) in 21 uprighted molars. Due to the scarcity of available evidence, the clinical relevance of these results could not be considered. Balance of benefit and harm Adverse effects such as tooth loss, abscess or decay were not reported in this study. Similarly, success and duration of orthodontic tooth movement, as well as subjective/objective evaluation of masti- catory function or PROMs were not reported. Due to the scarcity of available evidence, the balance of benefit versus harm of this type of combined perio-ortho therapy could not be assessed.
Legal considerations There are no apparent legal constraints.
R7.4. How should we manage stage IV periodontitis patients with tilted molars?
PICOS question addressed by a SR
R7.4: Expert consensus-based statement In stage IV periodontitis patients with tilted molars orthodontic therapy may be considered , although there is a lack of evidence on its possible effect on periodontal outcomes . Supporting literature (Kloukos et al., 2021) Quality of evidence Very low
(Continues)
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