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PubMed1987

Bond strengths of lingual orthodontic brackets bonded with light-cured composite resins cured by transillumination.

A method of curing light-cured composite resins by transillumination to cement acid-etched fixed partial dentures was adapted to bond solid mesh-backed lingual orthodontic brackets. Results of this investigation showed that the bond strengths of the orthodontic brackets bonded with light-cured composite resins were significantly less (P less than 0.05) than the bond strengths of the orthodontic brackets cemented with traditional adhesives and orthodontic composite resins. Notwithstanding, the bond strengths achieved with the transilluminated light-cured composite resins should be adequate to withstand the forces of mastication and orthodontic movements. There was no correlation of bond strengths of the brackets cemented with the transilluminated light-cured composite resins when compared to the faciolingual widths of the teeth.

Acrylic Resins↗
PubMed1987

The enkephalin response in human tooth pulp to orthodontic force.

Public perception is that dentistry and pain go hand in hand; thus, pain and pain control are important considerations to the profession. Recent studies have attempted to discover the precise metabolic events involved in neural transmission of nociceptive information. One focus has been the study of peptidergic pathways, which purportedly inhibit the firing of pain-conducting fibers. The research described in this article defined the existence of one enkephalin, methionine enkephalin (ME), in an extract of human tooth pulp tissue and the effect of orthodontic force on that ME concentration. One set of patients who had premolars extracted for orthodontic purposes served as controls. Another set, also diagnosed for premolar extractions, had a coil spring attached between the left and right maxillary premolars to supply an orthodontic force for a period of time prior to extraction. High-performance liquid chromatography, radioimmunoassay, radioreceptor assay, and mass spectrometry were used in a series of experiments to isolate, identify, and quantify ME in the pulp tissues. Principal results were as follows: for the first time ME was detected in human tooth pulp, orthodontic force caused a significant decrease in ME concentrations in the group of experimental teeth compared with controls, and ME levels of the first spring-attached tooth that was removed from each patient had a statistically significant inverse log-linear relationship to the amount of applied force. These data indicate that orthodontic force mobilizes at least one neuropeptidergic pathway in the human tooth pulp.

Chromatography, High Pressure Liquid↗
PubMed1987

Demineralization and remineralization around orthodontic appliances: an in vivo study.

The presence of clinically detectable areas of decalcification (observable as whitened areas) following the removal of orthodontic appliances is well recognized. The aim of the present study was to determine quantitatively the amount of demineralization and the ability of commercially available products to inhibit or reverse orthodontically related demineralization. Twenty orthodontic patients scheduled to have premolars extracted were randomly divided into four groups--one control and three test groups. The extracted premolars (numbering 58) were bracketed using an acid-etch composite system; each patient was given precise oral hygiene instructions and supplied with a sodium fluoride (1,100 ppm fluoride) dentifrice and an orthodontic toothbrush. The control group brushed only with the supplied dentifrice. In addition to brushing with the dentifrice, those in test group I rinsed once each night with a sodium fluoride (0.05%) mouthrinse; group II received a weekly topical APF treatment (1.2% fluoride); and Group III received a weekly topical APF treatment and rinsed once each night with the sodium fluoride mouthrinse. All premolars were extracted after 1 calendar month. Mineral profiles were determined on cross-sectioned teeth 50 to 75 micron occlusal and cervical to the brackets, directly underneath the brackets, and 500 micron away from the brackets. The control teeth (dentifrice only) demonstrated up to 15% demineralization to a depth of 50 micron. All of the test teeth produced rehardening and/or inhibition of demineralization (P less than 0.01). Those in test group III showed a particularly hard outer layer. The study demonstrated that measurable demineralization occurred around orthodontic appliances after only 1 month and this demineralization can be completely inhibited and/or reversed by the use of commercially available fluoride products.

Dental Bonding↗
PubMed1989

Clinical evaluation of a fluoride-exchanging resin as an orthodontic adhesive.

The purpose of this study is to examine the clinical durability and caries inhibition potential of a fluoride-exchanging resin (FER) when used as an orthodontic bracket-bonding adhesive. In the clinical durability investigation, orthodontic brackets were bonded to alternate teeth with the FER in 10 patients scheduled for routine orthodontic procedures. The remaining teeth were bonded with Concise orthodontic resin. Number of bonding failures and the site and mode (adhesive or cohesive) of failure were recorded. Also included in the study were 10 patients scheduled for orthodontic care with prescribed extraction of four first premolars. Bracketed teeth were extracted after 60 days and were sectioned and examined with polarized light microscopy using H2O and quinoline as imbibition media. Failure rates for the FER and Concise were 10.8% and 7.3%, respectively. Occurrence of adhesive rather than cohesive, failure indicates that structural integrity was maintained for both adhesives. Microscopic examination of specimens with H2O showed lesion formation to be 2.78% for the FER and 1.73% for Concise. These lesions were large and not seen in positions near the brackets indicating presence before bonding. With quinoline, dark zone formation was 2.3% for the FER and 33.5% for Concise, indicating a 93% reduction in the first stages of enamel alteration. Results demonstrate that the fluoride-exchanging resin holds promise as a practical caries-preventive adhesive.

Acrylic Resins↗
PubMed1989

The craniofacial morphology in persons with maxillonasal dysplasia (Binder syndrome). A longitudinal cephalometric study of orthodontically treated children.

The aim of this investigation was to study the influence of orthodontic treatment on facial growth in subjects with maxillonasal dysplasia. The subjects were followed longitudinally from early childhood until growth was completed or almost completed. Fifteen patients, 9 boys and 6 girls, were orthodontically treated by conventional methods. They were compared with (1) another longitudinal group consisting of 13 orthodontically untreated children, 7 boys and 6 girls with the same syndrome, and (2) with a control material taken from computer-filed data on Swedish children and young adults with orthognatic profiles and normal occlusion. The orthodontic treatment led to acceptable dental conditions in 10 of the patients. No influence on craniofacial growth could be demonstrated. However, the mean facial polygons of the children showed that certain differences already existed at early ages between the treated subjects with a generally more severe form of the syndrome and the untreated children. The growth pattern seemed, however, to follow about the same rate in both groups. In six patients the orthodontic treatment was followed by surgical correction at adult age to solve their craniofacial problems. The optimum care of these patients requires an interdisciplinary treatment approach with thorough treatment planning by orthodontists in collaboration with oral and plastic surgeons.

Cephalometry↗
PubMed1989

Effects of orthodontic force on methionine enkephalin and substance P concentrations in human pulpal tissue.

Orthodontic treatment typically involves intermittent periods of patient discomfort caused by forces on the teeth and adjacent tissues. This sensation of discomfort presumably is caused by the action of neuropeptides in the peripheral and central nervous systems. The effects of orthodontic force on the concentrations of two endogenous neuropeptides, methionine enkephalin (ME) and substance P (SP), measured as immunoreactive-methionine enkephalin (ir-ME) and immunoreactive-substance P (ir-SP), in human tooth pulp were evaluated in 20 patients from whom premolars were extracted before orthodontic treatment. The teeth from nine controls were not subjected to a force, whereas the 11 experimental patients had force applied to their maxillary premolars either by a transpalatal spring ligature or, in one case, by a headgear. The ligature applied a force within the range of 120 to 245 gm; the headgear applied 600 gm. Reversed-phase high-performance liquid chromatography (RP-HPLC) was used to purify the neuropeptides in the pulp homogenate, and radioimmunoassay (RIA) was used to quantify ir-ME and ir-SP in their appropriate HPLC fractions. (1) Females subjected to orthodontic force had significantly greater ir-ME concentrations than males. (2) The ir-SP concentration decreased significantly from the first to the third tooth extracted, then increased from the third to the fourth tooth. (3) Ir-SP and ir-ME concentrations are positively intercorrelated. The association was highest in the first tooth extracted from controls; surgical extraction decreased the correlation, although it continued to be positive. (4) The concentrations of ir-ME and ir-SP each correlated negatively with the magnitude of the orthodontic force and that correlation was enhanced when the value of the force was log-transformed.

Adolescent↗
PubMed1990

Shear bond strength of four orthodontic bonding systems.

Recently new orthodontic bonding systems have been developed for attachment of brackets to the etched facial surfaces of teeth. Two of these new systems use bonding agents that contain solvents. It is claimed that this improves the polymerization of the unfilled resin primer and may increase bond strength. A new light-cured restorative enamel/dentin-bonding agent has also recently been introduced. Its value in orthodontic bonding has not been determined. The aim of this investigation was to evaluate the shear bond strengths of the three new bonding systems and to compare these with a conventional orthodontic bonding system. Forty-eight enamel specimens were prepared with 600-grit silicone carbide paper, acid etched with 37% phosphoric acid, and assigned to four enamel-bonding treatment groups: (A) Saga sealant; (B) Maximum Cure; (C) Scotchbond-2; and (D) Concise enamel bond. After enamel priming, the specimens were bonded to Concise orthodontic bonding resin. The bonded specimens were thermocycled (15 degrees C to 45 degrees C) and then stored in distilled water at 37 degrees C for 7 days. Shear bond strength was tested with an Instron testing machine at a strain rate of 0.02 in/min. The mean shear bond strengths and standard deviations reported in MN/m2 were (A) 20.34 (5.37); (B) 25.33 (5.96); (C) 14.59 (5.25); and (D) 20.13 (4.98). The mean shear bond strengths for groups A, B, and D were significantly greater (p less than 0.05) than that for group C. The addition of solvents to the new orthodontic bonding systems does not appear to have a clinically significant effect. The new restorative bonding resin does not provide comparable enamel bond strengths.

Composite Resins↗
PubMed2003

In vivo study on metal release from fixed orthodontic appliances and DNA damage in oral mucosa cells.

Interest in the amount of metal ion intake from dental alloys has grown. Fixed orthodontic appliances usually include brackets, bands, and archwires made of stainless steel, nickel-titanium, or nickel-cobalt alloys, and these can release metal ions. The purpose of this study was to investigate the biocompatibility in vivo of fixed orthodontic appliances, evaluating the presence of metal ions in oral mucosa cells, their cytotoxicity, and their possible genotoxic effects. Mucosa samples were collected by gentle brushing of the internal part of the right and left cheeks of 55 orthodontic patients and 30 control subjects who were not receiving orthodontic treatment. The cells were immediately prepared for cell viability and the comet assay. Nickel and cobalt cellular content was quantified by inductively coupled plasma mass spectrometry (ICP-MS). The results indicate that nickel and cobalt concentrations were 3.4-fold and 2.8-fold higher, respectively, in the patients than in the controls; cellular viability was significantly lower in the patients than in the controls, and there was a significant negative correlation with metal levels. The biologic effects, evaluated by alkaline comet assay, indicated that both metals induced DNA damage (more cells with comets and apoptotic cells). There were significant positive correlations between (1) cobalt levels and the number of comets and apoptotic cells, (2) nickel levels and number of comet cells, and (3) cobalt levels and comet tails. This study corroborates that nickel and cobalt released from fixed orthodontic appliances can induce DNA damage in oral mucosa cells.

Adolescent↗
PubMed2005

The effectiveness of phase I orthodontic treatment in a Medicaid population.

BACKGROUND: The effectiveness of early orthodontic treatment for Medicaid-enrolled children in the mixed dentition was assessed and compared with results in a population of private-pay patients. MATERIAL: Pre- and posttreatment casts from 196 subjects treated with interceptive orthodontics in the mixed dentition were evaluated by using the peer assessment rating (PAR) index and the index of complexity, outcome, and need (ICON). Ninety-six of the patients were treated at Odessa Brown Community Clinic in Seattle; their treatment was paid by Medicaid. One hundred private-pay patients were treated at the University of Washington graduate orthodontic clinic. The Medicaid and private-pay populations were comparable with respect to initial severity of malocclusion, as assessed by both indexes. RESULTS: PAR and ICON scores fell by similar amounts in the Medicaid (44.1% and 37.5%, respectively) and private-pay (46.8% and 37.3%, respectively) populations. Thus, the groups exhibited similar degrees of improvement with interceptive orthodontic treatment. According to the PAR and ICON, midline discrepancy, overjet, and esthetics exhibited the greatest improvement. The Medicaid population missed significantly more appointments and had poorer oral hygiene than the private-pay group, but these factors did not appear to worsen the outcomes, as measured by the 2 indexes. An appliance with 2 bands and 4 brackets was the most commonly used, and it produced the most significant treatment effect. CONCLUSIONS: Phase I orthodontic treatment significantly reduces malocclusion severity in Medicaid and private-pay populations. There was no difference in initial severity or final outcome, as assessed by the PAR and ICON, between Medicaid and private-pay populations. The degree of improvement in PAR scores did not appear to be associated with compliance.

Analysis of Variance↗
PubMed2004

Clinical and microbiologic changes after removal of orthodontic appliances.

The goal of this study was to evaluate the clinical and microbiological factors associated with orthodontic appliances during an episode of gingival inflammation and the impact of appliance removal on periodontal health. This prospective study included 10 patients, aged 12 to 20 years, with clinical signs of gingival inflammation at the final phase of orthodontic treatment (appliance removal). Plaque index, gingival index, and probing depth were evaluated, and microbiological samples were collected from teeth 16, 11, and 26 at 2 times: during the gingival inflammation (baseline) and 30 days after the removal of the appliance and professional prophylaxis. Polymerase chain reaction analysis was used to detect Porphyromonas gingivalis, Bacteroides forsythus, Actinobacillus actinomycetemcomitans, Prevotella intermedia, and Prevotella nigrescens. A statistically significant improvement of the plaque and gingival indexes was seen, as well as a reduction in probing depth (P <.05). Periodontal pathogens were associated with gingival inflammation during orthodontic treatment. The improvement in periodontal health at 30 days was concomitant with a reduction of sites positive for A. actinomycetemcomitans and B. forsythus (P <.05). Periodontal pathogens associated with gingival inflammation during orthodontic treatment can be significantly reduced by orthodontic appliance removal and professional prophylaxis.

Adolescent↗
PubMed2005

Eligibility for publicly funded orthodontic treatment determined by the handicapping labiolingual deviation index.

INTRODUCTION: Access to orthodontic care for Medicaid patients has been limited, in part because of orthodontists' reluctance to treat severe malocclusions for low reimbursements. Limited orthodontic treatment in the mixed dentition (phase 1 treatment) has been proposed to address this issue, because the intent of phase 1 treatment is to improve or prevent severe malocclusions. Orthodontists might be more willing to provide shorter, simpler treatment. The purpose of this study was to determine whether phase 1 treatment would reduce malocclusion severity to the extent that eligibility for subsequent Medicaid-funded treatment was significantly reduced. METHODS: Eligibility was determined by the handicapping labiolingual deviation (HLD) index, which is used by several states for this purpose. Eligibility was also determined with the index of complexity, outcome, and need (ICON). This allowed us to compare these 2 indexes. Pre-phase 1 and post-phase 1 index scores were calculated by using study casts from 193 patients treated at the University of Washington orthodontic clinic and the Odessa Brown Children's Dental Clinic, both in Seattle. RESULTS: Using the HLD index, we found that eligibility for orthodontic treatment decreased by 62% after phase 1 treatment. This change was statistically significant at P < .0001. The ICON found significantly more treatment need before phase 1 (90%) than did the HLD index (35%) (P < .0001). CONCLUSIONS: Early interceptive treatment significantly reduces eligibility for comprehensive Medicaid-funded orthodontic treatment. The HLD index is a useful tool for determining Medicaid eligibility.

Adolescent↗
PubMed2005

Effect of fluoride prophylactic agents on the mechanical properties of nickel-titanium-based orthodontic wires.

BACKGROUND: Titanium-based alloys have high corrosion resistance because they form a thin, stable oxide layer. Nevertheless, fluoride prophylactic agents can cause corrosion and associated discoloration of titanium-based orthodontic wires. The purpose of this investigation was to study the effects of fluoride prophylactic agents on the mechanical properties of nickel-titanium (Ni-Ti) and copper-nickel-titanium (Cu-Ni-Ti) orthodontic archwires. METHODS: Preformed rectangular Ni-Ti and Cu-Ni-Ti wires were immersed in either an acidulated fluoride agent, a neutral fluoride agent, or distilled water (control) for 1.5 hours at 37 degrees C. After immersion, the loading and unloading elastic modulus and yield strength of the wires were measured with a 3-point bend test in a water bath at 37 degrees C, in accordance with the criteria in the current American National Standard/American Dental Association Specification No. 32 for Orthodontic Wires (2000). Scanning electron microscopy was also used to characterize the effects of the fluoride treatment on the wire topography. RESULTS: Unloading mechanical properties of Ni-Ti orthodontic wires were significantly decreased after exposure to both fluoride agents (1-way analysis of variance [ANOVA] and Dunnett's post hoc, alpha =.05); however, Cu-Ni-Ti wire mechanical properties were not significantly affected by either fluoride agent (1-way ANOVA, alpha =.05). Corrosive changes in surface topography were observed for both wires, with Cu-Ni-Ti appearing to be more severely affected. CONCLUSIONS: The results suggest that using topical fluoride agents with Ni-Ti wire could decrease the functional unloading mechanical properties of the wire and contribute to prolonged orthodontic treatment.

Acidulated Phosphate Fluoride↗
PubMed2005

Characterization of nickel-induced allergic contact stomatitis associated with fixed orthodontic appliances.

INTRODUCTION: In some orthodontic patients, an oral inflammatory response is induced by corrosion of orthodontic appliances and subsequent nickel release. This inflammatory response is manifested as stomatitis (nickel-induced allergic contact stomatitis [NiACS]). The etiology and diagnosis of NiACS are difficult to determine. The purpose of this retrospective analysis was to investigate the roles of age, sex, previous allergic history, and time of exposure to fixed orthodontic appliances in the etiopathogeny of NiACS. METHODS: Forty-four orthodontic patients (range, 10-44 years) were divided into 2 groups, depending on their NiACS clinical manifestations. RESULTS: Young patients, especially females with a history of allergic reactions, had a greater predisposition to NiACS clinical manifestations; time of exposure to orthodontic appliances was not a significant factor. CONCLUSIONS: A previous allergic reaction should be considered a predictive factor of NiACS clinical manifestations and should be noted in the patient's medical history.

Adolescent↗
PubMed2005

Malocclusion severity in Asian men in relation to malocclusion type and orthodontic treatment need.

INTRODUCTION: The purpose of this study was to assess the severity of malocclusion in young Asian men in relation to types of malocclusion and orthodontic treatment need. METHODS: Study models of 339 male army recruits (age, 17-22 years) with no history of orthodontic treatment were assessed. The peer assessment rating (PAR) index was used to determine the severity of their malocclusions. Logistic regression and receiver operating characteristics (ROC) curves were performed to evaluate the PAR index in relation to treatment need assessed by the dental health component (DHC) and the esthetic component (EC) of the index of orthodontic treatment need. RESULTS: The mean PAR scores were 17, 20, 28, and 18 for Class I, Class II Division 1, Class II Division 2, and Class III, respectively. PAR scores were highly correlated with DHC and EC scores (P < .001). An increase of 1 point in the PAR score significantly increased the likelihood of orthodontic treatment need for dental-health reasons or esthetic impairment (by 1.17 times [95% CI 1.13-1.21] or 1.25 times [95% CI 1.19-1.31]). The areas under the ROC curves for PAR index were 84% and 94% for the DHC and EC assessments, respectively, suggesting that PAR scores were better predicators of esthetic than dental health impairment for assessing Asian malocclusions. The optimum cutoff points were PAR scores of 17 and 20 for dental health and esthetic impairment, respectively. CONCLUSIONS: Class II malocclusions were more severe than Class I or III in Asian men. Malocclusions with definite treatment need had PAR scores that were significantly greater than those with borderline, little, or no need. ROC curves showed that the PAR index had an acceptable level of validity with the professional assessment of orthodontic treatment need in Asian malocclusions. The optimum cutoff PAR scores were 17 and 20 in relation to DHC and EC assessment, respectively. The PAR index was more predictive of esthetic than dental health need.

Adolescent↗
PubMed2006

The use of microimplants in orthodontic anchorage.

PURPOSE: Various types of temporary implants have been introduced to serve as orthodontic anchorage. The hypothesis of this study is that microimplants of 1.2 mm diameter can be used as orthodontic anchors, and that their success is related to their length. The aim of this study is to determine the incidence of anchor retention after orthodontic force application for moving teeth, and to determine the relationship of microimplant length to retention rate. METHODS: Fifty-nine microimplants (diameter: 1.2 mm) were placed in 29 patients as orthodontic anchorages. After 2 weeks of microimplant placement, a force of 100 to 200 g was loaded with an elastometric chain or NiTi coil spring. Risk factors were characterized as to why a microimplant may fail, and Fisher's exact test was used for statistical analysis. RESULTS: Nine microimplants were removed and the overall success rate was 84.7%. Exploring the causes for failure, we found significant differences between the length of microimplants and success rate; 6 mm was 72.2% and 8 mm was 90.2%. CONCLUSIONS: The results suggest that microimplants are suited as an alternative orthodontic anchorage. We recommend that 8-mm microimplants are preferable to 6-mm.

Adult↗
PubMed2006

The equity of access to orthodontic dental care for children in the North East of England.

OBJECTIVES: To assess the equity of access to primary care orthodontic treatment in relation to deprivation in the County Durham and Tees Valley Strategic Health Authority area. STUDY DESIGN: An observational study based on Dental Practice Board data for the County Durham and Tees Valley Strategic Health Authority area with a population of 1.13 million. METHODS: The postcode of all orthodontic claims made by National Health Service dentists across the area in the financial years 2002/2003 and 2003/2004 were obtained and the claim rate per 1000 at risk population calculated for each ward. These ward rates were then compared to both the level of deprivation measured by the Index of Multiple Deprivation 2000 and the children's dental registration rate of the area. RESULTS: Inequity in access to orthodontic care was observed. There was a moderate negative correlation r = -0.40 suggesting wards with the lowest claim rates had the greatest deprivation. In addition, the wards with the lowest child dental registration rates also had the lowest claim rates for orthodontic treatment. CONCLUSIONS: Currently, there is inequity of access to orthodontic treatment for children in County Durham and Tees Valley. The move towards local commissioning for dental services within the NHS will provide an opportunity to reduce inequalities in access.

Adolescent↗
PubMed2003

Shear bond strength comparison between direct and indirect bonded orthodontic brackets.

The purpose of this study was to compare the shear bond strength of orthodontic brackets bonded to teeth with either an indirect bonding technique and a new adhesive resin or a direct bonding technique and a light-activated adhesive. Fifty-four extracted premolars were mounted in acrylic blocks and randomly divided into 2 groups (n = 27). In one group, orthodontic brackets were bonded to premolars with an indirect bonding adhesive system; in the other, brackets were bonded with the direct method. Seventy-two hours later, the brackets were placed in a testing machine and subjected to a shear force with a crosshead speed of 1 mm/minute. The mean shear bond strengths for the indirect and direct groups were 11.2 and 10.9 MPa, respectively, both exceeding the minimum shear bond strength range of 5.9 to 7.8 MPa often cited in the literature for clinical success. Data were analyzed with Student t tests. No significant difference in shear bond strength between the 2 groups was detected (P =.76). Resin remnants on orthodontic bracket pads were observed with a dissecting microscope at 30x magnification and scored with a modified adhesive remnant index. There was no significant difference between groups (P >.05). There was also no correlation between shear bond strength and the percentage of adhesive resin remnants left on the orthodontic bracket. Under the conditions of this study, no evidence suggests a difference in shear bond strength of orthodontic brackets bonded to tooth enamel, whether they are bonded with the direct or indirect technique.

Dental Bonding↗
PubMed2003

Patient and parent understanding of informed consent in orthodontics.

In both medical and dental settings, researchers have found that patients do not adequately comprehend the information given during informed consent discussions, especially the less educated, low-income patients. Because of the importance of patient compliance with orthodontic treatment regimens, this study examined patient and parent understanding of the child's Phase I orthodontic treatment in a public dental clinic with ethnically diverse, low-income patients. Interviews were conducted with 29 children (ages 6-12) and their parents or guardians at the orthodontic case presentation appointment. The orthodontist explained the reasons for treatment, the orthodontic procedures to be used, the risks, the alternatives, and patient and parent responsibilities during treatment; the session was audiotaped. Interviews were conducted immediately after this discussion and the results compared with the orthodontists' presentations. In general, both children and parents recalled significantly fewer reasons for treatment (1.10, 1.66, and 2.34 items, respectively), procedures (1.55, 1.59, and 2.45, respectively), risks associated with treatment (0.66, 1.48, and 4.66, respectively), and responsibilities of the child during treatment (2.21, 2.07, and 3.38, respectively) than what the orthodontist had told them. They were also less likely to recall the reasons, procedures, and risks that were most frequently cited by the orthodontist. These findings raise concerns about the effectiveness of current informed consent techniques with public health populations, especially the low recall rates within 30 minutes of the case presentations. Low recall of risks by children and their parents, particularly for critical risks such as relapse, caries, and periodontal problems, raises concerns about treatment compliance, success, and more importantly, the effectiveness of the informed consent process itself. Future research should focus on methods to improve the informed consent process among children undergoing orthodontic treatment in a low-income population.

Child↗