Download a qualitative survey of orthodontic extraction related patient

A QUALITATIVE SURVEY OF ORTHODONTIC EXTRACTION RELATED
PATIENT INFORMATION AVAILABLE ON THE WORLD WIDE WEB
Chelesa R. Phillips, D.D.S.
A Thesis Presented to the Graduate Faculty of
Saint Louis University in Partial Fulfillment
of the Requirements for the Degree of
Master of Science in Dentistry
2014
COMMITTEE IN CHARGE OF CANDIDACY:
Associate Professor Ki Beom Kim
Chairperson and Advisor
Professor Eustaquio Araujo
Associate Clinical Professor Donald Oliver
i
DEDICATION
I dedicate this project to my faithful cheerleaders
who have supported me along this journey, from fifth grade
to the present. To my parents, Cleo and Roystan, for their
5:00 AM wake-ups since 1997 and for constantly showing me
that I am never alone in my fight to succeed. I owe you
both my success. Thank you. To my brother, Jovel, who is a
bigger motivator and inspiration to me than he will ever
realize and a guaranteed smile in my day. And to Michael
Clymer, for having the motivation and enthusiasm all the
times that I did not and for being by my side through this
whole process, sometimes even allowing me to keep the light
on. I appreciate you all. I love you all. Thank you from
the bottom of my heart.
ii
ACKNOWLEDGEMENTS
I would like to acknowledge the following individuals:

Dr. Kim, for assuring me that this project was doable
when I had my doubts and for making me see bigger than
my own dreams. Thank you for your constant
cheerfulness, enthusiasm, and interest. And thanks for
making me think outside the box (clinically and
thesis-wise).

Dr. Araujo, for listening to every one of my thesis
ideas and making me think that each one was the best.
I appreciate your passion and I respect you immensely
as an orthodontist. I want to be just like you when I
grow up.

Dr. Oliver, for reading all of my drafts and providing
articles for me to read that you found in your morning
newspaper. Your care for your students and dedication
to the field truly shows. I appreciate your
contributions to my education and will never forget
you and your witty charm. Go Bears!

Dr. Johnston, for not shooting down my first idea.
iii
TABLE OF CONTENTS
List of Tables............................................v
List of Figures.........................................vii
CHAPTER 1: INTRODUCTION...................................1
CHAPTER 2: REVIEW OF THE LITERATURE
Orthodontic Extractions.........................4
History....................................4
Non-extraction Orthodontics...............13
Health Information on the Internet.............25
Summary and Statement of Thesis................31
References.....................................32
CHAPTER 3: JOURNAL ARTICLE...............................39
Abstract.......................................39
Introduction...................................41
Materials and Methods..........................44
Results........................................47
Discussion.....................................68
Conclusions....................................84
References.....................................85
Appendix A...............................................87
Appendix B...............................................89
Appendix C...............................................95
Vita Auctoris...........................................123
iv
LIST OF TABLES
Table 3.1:
Search results for each search term
categorized by website type.................49
Table 3.2:
Search results for each search term
categorized by authorship...................51
Table 3.3:
Search results for each search term
categorized by extraction stance............53
Table 3.4:
Stance on orthodontic extraction
categorized by website type.................55
Table 3.5:
Stance on orthodontic extraction
categorized by website authorship...........58
Table 3.6:
Top ten search results per neutral
search term.................................61
Table 3.7:
Top ten search results per biased
search term.................................61
Table 3.8:
Top ten search results per control
search term.................................62
Table 3.9:
Extraction stance of the top three
search results per search term..............63
Table 3.10:
Website type of the top three search
results per search term.....................64
Table 3.11:
Website authorship of the top three
search results per search term..............66
Table 3.12:
Google click distribution and amount
of time spent per website according to
search result position......................75
Table B.1:
Classifications used to assign
website type................................89
Table C.1:
Unfiltered Search Results for the Search
Term “orthodontic extractions”..............95
v
LIST OF TABLES: Continued
Table C.2:
Unfiltered Search Results for the Search
Term “braces extractions”...................98
Table C.3:
Unfiltered Search Results for the Search
Term “braces extractions good or bad”......102
Table C.4:
Unfiltered Search Results for the Search
Term “orthodontics without extractions”....105
Table C.5:
Unfiltered Search Results for the Search
Term “braces without extractions”..........109
Table C.6:
Unfiltered Search Results for the Search
Term “non-extraction orthodontist”.........112
Table C.7:
Unfiltered Search Results for the Search
Term “braces”..............................116
Table C.8:
Unfiltered Search Results for the Search
Term “orthodontics”........................119
vi
LIST OF FIGURES
Figure 2.1:
Extraction rates in the United States in
the 20th Century.............................10
vii
CHAPTER 1: INTRODUCTION
The extraction debate has existed in the field of
orthodontics almost since the origin of the specialty
itself.1,2 Over one hundred years later, orthodontists
continue to dispute the extent to which extractions are
necessary for successful treatment.3 With the advance of the
Internet Age, this debate has since extended to the web to
be viewed by orthodontists, dentists, and patients alike.
With patients taking greater charge of their healthcare
decisions and performing their own research, the internet
is often considered a valuable information source. However,
this information could also be detrimental to the patient
if it is not reliable and supported by evidence-based
research and findings.
It has yet to be decided what the ideal orthodontic
treatment choice should be in regard to orthodontic
extractions. While extractions are employed by most
orthodontists, the frequency with which they are
recommended varies widely – from a reported low of 5
percent to a high of greater than 75 percent4-7 - and has
changed over the decades with the evolution of new
philosophies and the reemergence of past ideas.6 However,
many orthodontists and general dentists continue to
1
advocate for extremely low numbers of extractions, often
using non-evidence-based claims to steer patients away from
extraction treatment. The majority of available research
shows that, when applied judiciously, extractions are part
of an appropriate treatment method and often the
recommended choice by the majority of orthodontists. With
this said, those practitioners (as well as general
dentists, previously or currently treated patients,
orthodontic product and appliance companies, etc.) who are
adamantly vocal about extractions being detrimental to
orthodontic treatment outcomes in almost all cases may be
providing a disservice to patients seeking information
concerning whether extractions may or may not be
appropriate for them.
This study investigated the nature of available
information about orthodontic-related extractions
specifically found on the internet. It assessed websites
discussing this topic and determined whether there was a
greater likelihood for a layperson seeking information to
find information in support of or against treatment with
extractions. In addition, the study evaluated what type of
website a layperson is most likely to find, whom is
authoring what type of information, and whether the
2
existing biases of the searcher altered the type of
information that they are most likely to find.
3
CHAPTER 2: REVIEW OF THE LITERATURE
Orthodontic Extractions
History
The debate over the extraction of teeth for the
purposes of orthodontic treatment has been the source of
extensive and often heated debate for over a century.
Extractions are frequently prescribed by orthodontists for
the purpose of making space to achieve the desired goals of
their treatment. They are most often used to alleviate the
crowding or protrusion of the teeth as well as to
camouflage skeletal and dental malocclusion.8 While there is
significant evidence to support that this practice is
clinically sound, many practitioners feel that the
extraction of healthy teeth solely for orthodontics is
unwarranted.
Edward H. Angle, considered the father of modern
orthodontics,9 shaped many of the founding principles of
this field. In addition to creating the first orthodontic
school, journal, and society - thus making orthodontics a
recognized and distinct medical specialty - Angle was very
interested in the “regulation” of teeth and produced the
first practical classification of malocclusions. The Angle
4
Classification, published in 1899, remains the most
commonly used classification of malocclusions today.10
As Angle developed his definitions of what constituted
an ideal occlusion, he struggled with the issues of facial
esthetics and post-treatment stability.11 He was influenced
by the philosophy of Jean-Jacques Rousseau and,
particularly, his emphasis on the perfectability of man.
Angle shared a sentiment common among other progressive
dentists of the 1890s that people were too careless with
the decision to extract teeth, especially in an era where
modern advancements allowed for the restoration of the
teeth. It became Angle’s goal to reach perfection in all of
his cases by restoring or creating the ideal relationship
of all 32 natural teeth. As such, he concluded that
extraction solely for orthodontic purposes was never
needed.8
Wolff’s discovery of the internal architecture of bone
and its response to external stresses in the early 1900s
formed the groundwork for Angle’s two key concepts. The
first was that skeletal growth could be readily altered by
external pressures. He reasoned that the etiology of
malocclusion, consequently, was abnormal stress on the jaw
that, when altered by orthodontic intervention, could
5
change growth in such a way that the problem could be
overcome. Angle’s second concept stated that proper
function of the jaws was imperative to maintain teeth in
their correct position. He felt that when teeth were in
their proper location, the forces transmitted to the bone
by the ideal occlusion would stimulate bone formation that
would help to stabilize the teeth in their new position,
even after arch expansion. This led Angle to coin his
appliances that helped to move the teeth to these ideal
positions as a “bone growing appliance.”8 Angle advised that
relapse after treatment could only be caused by the teeth
not being in their ideal position and, if relapse did
occur, such ideal positioning had never actually obtained
due to some incompetence of the treating orthodontist.8
Angle, in a quest for the ideal facial form, sought
out advice from Wuerpel, a famous artist and art professor.
Wuerpel ridiculed his pursuit, stating that the large
variation in human faces made it impossible to quantify any
one form as ideal. From this, Angle determined that the
ideal face must, as such, be formed on an individual basis
and uniquely to each individual once the teeth were placed
in an ideal occlusion, regardless of the outcome and
effects on appearance.8
6
Calvin Case did not agree with Angle’s justification.
He argued that esthetics and stability would be an issue in
the long term for many patients with such treatment. The
quarrel between the two schools of thought would eventually
peak in a very public dispute - the “Great Extraction
Debate” - between Case and Dewey, one of Angle’s disciples,
on the pages of the 1920s’ dental journals.10,12
Surprisingly, while much of our current evidence-based
literature is in favor of Case’s claims, Angle’s ideas
would eventually come to dominate the orthodontic landscape
and extraction numbers would drop to drastically low levels
until well into the 1940s.8
Despite their faithfulness to Angle’s non-extraction
principles, by the 1930s, many orthodontists were seeing a
high frequency of relapse in their cases.8 Charles Tweed,
one of Angle’s last students, made the bold decision to
retreat several of his own cases showing relapse with four
first bicuspid extractions in hopes of achieving greater
stability. Tweed believed Angle’s previous non-extraction
theory had caused many distorted facial profiles and
unstable alignments of the teeth.13 He found that, postextraction treatment, the occlusion of these patients was
much more stable than their initial post-treatment results
7
had been and suggested that this was due to the proper
upright placement of the mandibular incisors over basal
bone now afforded by the extractions.14 When Tweed presented
these findings to the greater orthodontic community, it
sparked an immediate revolution in the beliefs of the time
and, by the late 1940s, extraction treatment was once again
widespread in orthodontic practice.8
At the same time on the other side of the world,
another of Angle’s students, Australian Raymond Begg had
also determined that non-extraction treatment produced
unstable results. In addition, Begg had completed a study15
on the dentition of the Stone Age man in which he found
that these people experienced a gradual reduction in tooth
size due to a much more course diet. The interproximal wear
of the enamel during function was suggested to create space
in the arch that consequently led to a lower prevalence of
dental crowding and third molar impaction. With our present
diet not being substantial enough to cause this type of
attrition, Begg came to the conclusion that premolar
extractions would replicate the space that was no longer
being physiologically produced and, as such, would produce
much more ideal and stable occlusions. This led him to
develop a new appliance, a modification of Angle’s ribbon
8
arch, which allowed for successful extraction
treatments.8,15-17
Consistent with this era of evolving ideas, the
results of an influential study by Stockard18 in 1941
introduced the new concept of malocclusion heritability to
the field of orthodontics. This new finding refuted Angle’s
concept that one could overcome skeletal discrepancies by
developing patients’ growth potential. It instead suggested
that such a potential is simply not present in many
patients and that the orthodontist must come to recognize
genetically determined disparities between jaw size and
tooth mass. In these recognized cases, extraction was
indicated and would be necessary for a stable result. By
the 1960s, the extraction/non-extraction pendulum had swung
to yet another extreme with more than half of all
orthodontic patients having treatment-related extractions
for the purposes of crowding or jaw discrepancies.6,8
In the 1950s, Proffit began a study at the University
of North Carolina that effectively documented the changing
tide of such national and global extraction trends (Figure
2.1)6,8. He found that, at the inception of the study,
treatment in the university clinic was predominantly nonextraction, following the tenets of Angle that were so
9
popular at the time. However, with the spread of Tweed and
Begg’s findings and Stockard’s new ideas, extraction rates
increased dramatically, peaking in the 1960s. There was a
constant decline in extraction numbers from then until the
1990s, where the rate plateaued at close to the rates of
the Angle era.6,8
80
Percent with extractions
70
60
50
40
30
20
10
0
1900
1920
1940
1960
1980
2000
Figure 2.1: Extraction rates in the United States in the
20th Century6,8
While the reemergence of extractions in the 1930s was
primarily triggered by the quest for greater stability than
that seen with Angle’s non-extraction treatment, the
decades of extraction treatment to follow showed that
premolar extraction may not be the best solution either. As
evidence-based dentistry moved to the forefront, numerous
studies were published19,20 showing that extraction treatment
10
fails to guarantee stability as well. This helps to explain
the decline in extraction rates in more recent decades.
With neither philosophy being especially stable, a logical
argument could be made that, in the absence of other
significant factors, it is better to avoid removing healthy
teeth.8
Other factors leading to the decline in extraction
rates include a shift in cultural standards of facial
attractiveness. People today tend to prefer fuller, more
pronounced lips than what was considered desirable in the
1950s and 1960s. Non-extraction treatment currently tends
to produce esthetically pleasing results for the modern
patient with a “non-extraction” or “borderline” face and
has become the treatment of choice for those without
significant incisor or soft-tissue protrusion necessitating
premolar extraction.8
Additionally, the extraction rate was negatively
impacted by reports in the 1980s of temporomandibular
dysfunction caused by extraction of upper premolars. While
several studies21-23 have been published disproving this
claim, the stigma still remains and is currently promoted
by many dental and medical professionals. Other new
advances in orthodontics – the advent of functional
11
appliances and interproximal reduction as well as an
increase in early intervention and space maintenance
techniques – have reduced the incidence of extractions by
the year 2001 to around 25-30%24, similar to the numbers
recorded by Proffit6.
Currently, one is able to find orthodontists and
general practitioners representing the full spectrum of
opinions in regard to the appropriate use (or lack thereof)
of extractions in orthodontic treatment. Most detrimental
to the field are those that subscribe exclusively to the
extremes of this spectrum in either direction, blatantly
ignoring the existing scientific literature. As the famous
quote by Santayana goes, “those who cannot remember the
past are condemned to repeat it.”25 Similarly, it is
imperative that we, as a specialty, remember where we have
come from. Exclusive expansion treatment was done for much
of the last century and it failed. Conversely, the
indiscriminate use of extractions has also been attempted
and this, too, has failed. It is important that we learn
from the mistakes of our past, having visited both extremes
of the extraction/non-extraction continuum, and we perhaps
consider making the decision as a specialty to settle
somewhere in the middle.
12
The extraction controversy is likely to persist for
some time to come as no one to date has been able to find
concrete data to settle the score. However, with the everincreasing focus on evidence-based orthodontics, there is
hope that the field will one day move from that of several
vastly differing opinions on the matter to one
scientifically-based fact.
Non-Extraction Orthodontics
Extractions have been prescribed for the purposes of
orthodontic treatment for well over a century now. There
are several reasons why orthodontists feel that extractions
may be necessary, including:
-
the creation of space to align the teeth in cases of
inadequate space availability (crowding) in the
dental arch8,26,27;
-
the reduction of incisor protrusion8,27;
-
profile/soft tissue improvement or camouflage of
Class II or III skeletal malocclusions8,26,27;
-
detrimental effects to the stability of the teeth,
gum tissue, or esthetic appearance of the teeth and
soft tissue if the teeth were to be aligned without
extractions26,27;
13
-
bite correction and overjet severity, particularly
for difficult Class II malocclusions26,27;
-
midline correction26,27;
-
tooth size anomalies27;
-
reduced growth potential27;
-
maintenance of the existing profile27;
-
closing down the bite27; and
-
anticipation of poor cooperation, among other
reasons27.
The common alternative to orthodontic extraction for
crowding purposes is expansion either with an expander
appliance or broad archwires. Other options to address this
issue include distalization of the posterior teeth to make
more room or other mechanics along these lines with or
without the assistance of temporary anchorage devices. In
the case of skeletal discrepancies, alternative treatments
include growth modification or orthognathic surgery.8
The decision to extract is complex and several factors
should be taken into account when treatment planning each
case, including the bite, midlines, amount of crowding,
position of the jaws, position of the teeth, future
potential for growth, sizes of the teeth, soft
tissue/profile, and other attributes.26 It is not
14
necessarily prudent for an orthodontist to subscribe
strictly to a philosophy of extraction or non-extraction.28
Rather, each case should be looked at individually and a
decision made based on the complete records obtained.
Nonetheless, there are several orthodontists as well
as general dentists that choose to market themselves as
non-extractionists, making claims that extractions are
detrimental to the well-being of the patient. One of the
more prominent non-extractionists, John Witzig, made
several claims in the 1980s and 1990s about the supposedly
harmful effects of extraction treatment, professing that
“the extraction of bicuspid teeth leads to the ‘dishing in’
of the face and ruins the facial profile” and that “the
extraction of bicuspid teeth during orthodontic treatment
is directly correlated to the incidence of post-orthodontic
TMJ dysfunction.”29,30 Though unsupported, these assertions
unfortunately have spread throughout the dental community
and to the general public at large, even reaching
international airwaves in a popular interview and debate in
2003 between opponents and advocates of orthodontic
extractions on primetime television show 60 Minutes.31
However, it is a simple fact that non-extraction
treatment does not have a strong scientific basis. Many of
15
the studies published supporting non-extraction
philosophies are case reports or opinions written in
editorial or textbook form which, according to the
hierarchy of evidence32, do not provide adequate scientific
support for the claims made in such reports. There are no
published evidence-based studies that properly demonstrate
that extractions negatively affect the profile, smile, or
temporomandibular joint.26
Nevertheless, Witzig’s assurances for a more simple
and supposedly beneficial non-extraction treatment went on
to facilitate the development of several less than credible
weekend courses in orthodontics for general dentists along
with their certification by fabricated “orthodontic
associations” made up to mislead the unknowing consumer. On
the other hand, however, he simultaneously stimulated the
orthodontic profession to investigate and attempt to defeat
his claims with true science and evidence-based methods16.
As such, numerous studies21-23,33-51 were published that
disprove the unsupported claims made by the pushers of nonextraction treatments.
Appropriately, even the more prominent orthodontists
took a stand against the non-extractionists’ claims. Lysle
Johnston, in particular, was notably outspoken and harsh in
16
his critiques of the unscientific approaches and
declarations of those against extractions. He led or
participated in several studies21,35,36,41 directed at
disproving their statements and supporting the existing
evidence that extractions are not harmful when used
appropriately.16
Bowman completed a study with Johnston41 in 2000 that
looked at the profile changes of Caucasian patients as
assessed by laypeople and dentists after the completion of
extraction and non-extraction treatments. They concluded
that those treated with extractions saw a positive change
in their profile when they had initially crowded and
proclined teeth. To the contrary, non-extraction treatment
was found to actually have a negative effect on the
profile.
Erdinc et al42 also evaluated long-term changes in soft
tissue profile in patients treated with or without
extractions and found no differences. Similar results were
found in the study by Stephens et al which concluded that
extraction and non-extraction patients ended up with
similar profiles after orthodontic treatment.40 Bokas and
Collett43 determined that there was minimal change in the
position of the upper lip after camouflage treatment of
17
Class II Division 1 malocclusions with extractions, also
supporting the finding that extractions do not
significantly affect the profile.
The take-home message in regard to profile change, as
Bishara39 and Basciftci37 both concluded from their
investigations, is that extractions treatment, when
diagnosed correctly and prescribed appropriately, has no
negative affect on the profile. Bishara proved in his study
that profiles were not damaged by extractions, going on to
state that, “when based on proper diagnostic criteria, the
post-treatment changes in the facial profile were perceived
as favorable in both the extraction and non-extraction”
patients.39 Basciftci felt that the one-dimensional belief
that all extraction treatments produced the same results in
all patients was unreasonable. He declares in his paper
that “the simple statement that extraction means a more
retrusive or dished-in profile seems unacceptable. It seems
that a more thorough assessment and investigation including
pretreatment extent of crowding and factors related to
anchorage, soft tissue thickness, and strain should be
carried out.”37
Often, advocates of non-extraction orthodontics make
the claim that cases where many other orthodontists would
18
extract can often be easily treated by simply expanding the
arch. For this reason, they make the unreasonable
suggestion that teeth never have to be extracted. It is
true that expansion is able to provide additional room in
the arches. However, in some cases, this additional space
simply may not be enough to fit all the teeth without
moving the dentition past biologically reasonable limits.
Overexpansion in order to fit all of the teeth commonly
relapses due to the reciprocal force of the tissues once
the teeth are moved past their point of physiologic
balance. If the anticipated amount of expansion necessary
to accommodate all of the teeth is significant and thus
probable to relapse, it is more ideal to perform
extractions to create the needed space.52 In fact, the
instability of the routinely expanded arches of Angle’s day
helped to usher in the pro-extraction era of the 1950s and
1960s.3
Furthermore, there is no reliable way to expand the
lower arch, and such attempted expansion is scientifically
proven to relapse when the inter-canine width is
increased.8,16,20,53,54 Some non-extractionists claim that
expansion of the mandibular arch is stable if the maxillary
arch is expanded. No evidence supports this. To the
19
contrary, Gryson’s study44 on mandibular interdental
distance in relation to rapid maxillary expansion showed
that there was no correlation between changes in the two
arches. He goes on to say that the use of maxillary
expanders as a means to increase lower arch length cannot
be justified.
Opponents of orthodontic extractions also make the
claim that extractions negatively affect smile esthetics,
causing dark buccal corridors that narrow the appearance of
the smile. They suggest that non-extraction/expansion
treatment produces wider, more esthetically pleasing
smiles16 - “Hollywood” smiles as some like to call them.
Isiksal et al45 had a group of orthodontists, plastic
surgeons, general dentists, artists, and patients compare
the smile esthetics of patients treated with and without
extraction. The researchers not only found that there was
no difference between the perceived attractiveness of the
two groups but also determined that the extraction group
actually had wider arches than the non-extraction group.
This is in line with the conclusions of the studies
performed by Johnson and Smith46 and Gianelly47 that found no
difference in smile esthetics between patients treated with
and without extractions. The study by Kim and Gianelly38
20
also lends further support for lack of an effect on arch
width, stating that “arch width is not decreased at a
constant arch depth because of extraction treatment, and
smile esthetics are the same in both groups of patients.”
The next allegation made by extraction opponents is
that the extraction of premolars can lead to temporomandibular dysfunction, supposedly due to retraction of the
teeth posteriorly which affects the function of the muscles
of mastication which, in turn, affects resting position and
produces symptoms, among other potential reasons. Beattie,
Paquette, and Johnston conducted a retrospective study of
63 initially Class II patients who were considered
“borderline” for extraction to determine if there was
difference in temporomandibular joint symptoms due to the
the extraction of premolars. No significant differences
were found between the groups, leading to the conclusion
that “the present data therefore fail to support the
popular notion that “premolar extraction causes ‘TMJ’
[sic].”"21 Similarly designed studies by Kremenak et al22 and
Kundinger et al48 also came to the same conclusion that
there was no difference in TMD data between extraction and
non-extraction groups.
21
While non-extractionists make several negative claims
about premolar extraction, they often conveniently fail to
mention the shortcomings of their own philosophy. Beyond
the issues of instability discussed previously, overexpansion of the dental arches in order to make room for
all the teeth in a crowded dental arch often results in
excessively proclined teeth, especially in patients with
crowded mandibular incisors that are treated without
extractions.49,50 Such proclination can be detrimental to the
post-treatment periodontium. The study by Yared et al51
showed that proclining the mandibular incisors to an
incisor-mandibular plane angle greater than 95º with
decreased gingival thickness of less than .5 mm increased
the severity and amount of recession at the central
incisors.51 This type of recession can have long-term
effects, compromising the longevity of the teeth and
potentially increasing stability concerns.
With the large amount of evidence provided - which is
not an exhaustive list by any means - it is very clear that
extractions do not have a negative effect on the profile,
smile, or temporomandibular joint health of the patients
undergoing such treatment when diagnosed and prescribed
appropriately. As such, it is a reasonable conclusion, as
22
Bentele wrote, that “Witzig and his ilk were long on
opinion but short on paying attention to a couple millennia
of scientific method.”16
In similar fashion, much of the existing orthodontic
literature continues to be conveniently ignored by many
across the profession due to the lure of greater profit
potential, easier treatment mechanics, or more appealing
marketing.3 There are several examples of claims made in
print, on the internet, on television, and from
orthodontists’ own mouths that promote something along the
lines of a “full dentition yields a full smile, a better
profile and, for most people, better midface support”.55 As
has occurred in the past, the majority of these claims are
not followed up with any supporting evidence, and according
to Burrow, “completely [undermine] evidence-based
orthodontics.”3
Perhaps the most famous non-extractionist to date is
Edward Angle, who was a firm believer that the best
orthodontic outcomes required a “full complement of
teeth.”56 However, even Angle claimed that extractions were
appropriate if “the jaws are small and the angles of
inclination would be too great” or if “placing the teeth in
the line of occlusion would result in marked dental and
23
labial prominence.”11 If he, the founder of non-extraction
treatment, can admit that there is a time and place for
premolar extractions, is it not reasonable to think that
current practitioners, with all the available evidence,
should feel the same?
Non-extraction treatment is a method of practice and
it is incorrect to consider it as a goal in individual
treatments or practice as a whole.16 It is imperative that
each malocclusion is reviewed on a case by case basis and
in totality. Subscription solely to one philosophy or
another is inappropriate and a disservice to the patient.
Furthermore, this type of practice blatantly disregards
established and well-documented practices over a century
old. There are situations in which non-extraction treatment
would be the best method. Conversely, there are other
scenarios in which extractions are the best treatment
choice for the patient. The decision to extraction should
always be made on an individual basis and specific to each
the patient’s unique physiology. Ultimately, it comes down
to the following conclusion by Mark Bentele: “Science tells
us that extraction is a valid tool in orthodontic
treatment. The art is how to apply that tool.”16
24
Health Information on the World Wide Web
With an estimated 2.8 billion people around the world
using the internet on a regular basis as of this year,57 the
internet has become an indispensable tool in our daily
lives. It has been calculated that 85 percent of North
Americans are internet users57 and this percentage continues
to grow every day, undoubtedly due to its great appeal to
the masses – consumers, academics, professionals, and
entertainment seekers alike. The internet is an
interconnected global web of computer systems, a network of
networks linking people and entities all around the world
for the purposes of information sharing, communication, and
several other transactions in the private, public,
commercial, academic, business, and government sectors.58
While the internet has been a source of information
retrieval from its inception, its natural allure has
developed into something much more with the introduction in
the 2000s of Web 2.0. This new generation of internet was
in stark contrast to the more “primitive” Web 1.0 which
simply limited users to accessing a hierarchical system of
content governed by webmasters and offering static webpages
with no capability for interaction or manipulation by the
viewer.59 Web 2.0 changed the scene completely, with
25
“powerful tools designed to enhance creativity, information
sharing, collaboration, and functionality of the web, and
to transfer power to the end user.”59,60 These new
advancements – technologies such as blogs, podcasts, search
capabilities, tagging, social networking, video sharing,
Wikis, and the like - allowed users to add, modify,
personalize, and delete web content on their own or in
collaboration with other users59,60 and was the start of the
internet that society has come to so strongly embrace
today.
However, while such flexibility and independence may
create an invaluable breeding ground for the spread of new
ideas and valuable opinions, it also provides a medium for
the potential publication and distribution of
misinformation, as the vast majority of internet
contributions lack any form of peer-review.61-63 With the
ability of anyone who desires, regardless of credentials
(or the lack thereof), to readily contribute to its
infinite array of content, the internet provides a
convenient channel for those intending to push their own
agendas and personal philosophies which may or may not be
based in fact. The difficulty with this is often the
26
inability of the untrained reader to separate the “wheat
from the chaff”.64-66
This has become a large problem as more and more
people turn to the internet as a major source of personal
health information and advice. The National Health
Interview Survey, completed in 2009, found that more than
50 percent of surveyed adults had used the internet to
search for health information during the 12 months previous
to the study.67 Previous to that research, the Pew Internet
and American Life Project estimated that up to 80 percent
of all internet users have searched for online health
information, with 15 percent of users seeking dental health
information in particular.68
Of these patients seeking such online resources, 70%
report that the information that they find during their
search influences their health care decision making.69 This
is a change from the paternalistic ideals of the past where
the doctor often determined the patient’s problem and what
treatment they should undergo without input from the
patient.70 Today, people are more questioning and better
informed and they expect to play a greater role in their
own health care.66 Society’s internet obsession easily
facilitates and perpetuates this desire.
27
With such a great number of Americans, an estimated
160 million71, flocking to their computers for medical
advice, it is a natural concern that such an unregulated
and potentially erroneous source of information may be
leading some astray.66,72,73 This has led several researchers
and medical professionals to more closely scrutinize and
attempt to evaluate the accuracy and quality of the content
that patients are likely to find in their internet queries.
Numerous tools and assessments have been developed over the
past decade to help the reader and the health professional
attempt to quantify how reliable a health website might be.
However, with over 270 instruments being used currently and
more being developed every year, there seems to be no
definitive way to evaluate these websites.59,74-77 In
addition, with so many potential authors – essentially
anybody with an opinion and an internet connection –
producing new websites and discussion boards daily, there
is truly no way to monitor and regulate all available
information at any one time. This has led some to wonder if
attempting to evaluate and regulate online health
information sources is a futile undertaking, if even
possible at all.78
28
Numerous studies61,63-66,69,72,75,77,79-83 have attempted to
evaluate the quality and validity of health-related
websites for several medical fields. Across the board,
these studies all conclude that the information available
via internet search engines is variable and that few of the
websites evaluated have met the target minimal quality
standards of the assessment tools applied.61,83 In addition,
the studies have demonstrated that the top-ranked websites
are not necessarily those of the highest quality or
reliability.64,83
The results of the study by Patel and Cobourne83 on
orthodontic extraction information in particular found that
while the readability of the websites evaluated was
relatively good, reliability of the information was
concerning and that patients should take any advice
provided via these resources with caution. These findings
are similar to the results of several of the other studies
for various other medical conditions.
Other studies have pointed out that, while there are
several resources available to patients seeking health
information online, many patients have trouble identifying
the most useful, credible, or reliable sites.64 Several
researchers have made the suggestion that it is our
29
responsibility as healthcare professionals and educators to
identify those websites that are most credible and guide
patients to these credible and validated websites.61,66,79
More importantly, while many of our patients are
turning to the internet for generic information about the
conditions that interest them, it is imperative that we as
health professionals remember our role as the primary
health care provider and do not allow this supplemental
source of information to lessen our responsibility to our
patients to provide them with personalized information
based specifically on their unique situations and
conditions.64
30
Summary and Statement of Thesis
This study will investigate the nature and quality of
information available about orthodontic-related extractions
found specifically on the internet. Qualitative statistics
will be derived to evaluate the proportion of information
published in support of and in opposition to extraction
treatment on the websites most likely to be accessed by
patients. In addition, comparison of characteristics such
as the type of website, the title/profession and
credentials of the author, and website search engine
optimization rank will be made relative to their
corresponding stance on treatment. The study will attempt
to evaluate whether biases exist in the type of content to
which the researching patient is most likely to be exposed.
31
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38
CHAPTER 3: JOURNAL ARTICLE
Abstract
Purpose: This study investigated the nature and
quality of information available about orthodontic-related
extractions found on the internet. Methods: Several key
words related to orthodontic extractions were entered into
the Google search engine. The top 100 websites returned for
each search were analyzed to determine the type of website,
authorship, American Board of Orthodontics certification
where applicable, use of references, and the stance of the
website on the practice of extractions for orthodontic
purposes. Results: Of the 558 website results, more than
50% of the webpages exhibit general support for extraction
treatment. Approximately one quarter of the results lack
support for orthodontic extractions. Fifty percent of the
search results were authored by orthodontists. This
demographic was shown to predominantly support the use of
extractions. Another 17.5% were authored by general
dentists who have a higher likelihood to promote nonextraction treatment. Sites authored by patients or
laypeople tend to lack support for orthodontic extraction
and are more likely to be accessed when utilizing search
terms with more colloquial language. A searcher utilizing
39
neutral search terms will receive variable search results
generally in support of extractions. Biased search results
produce a noticeably greater amount and proportion of nonextraction search results. This was particularly
significant within the top search results and greatly
increased the likelihood of viewing information promoting
non-extraction treatment. Often, the top search results per
search term were not held by the most credible sources.
Conclusions: The majority of the information found was
authored by orthodontists and supported the practice of
orthodontic extractions. However, the study found that
general dentists heavily promote non-extraction treatment
and their content was just as likely to be viewed as
orthodontist-produced content due to their position in the
search result rankings. In addition, the type of search
results returned for a particular query is affected by the
bias and language choice of the particular search term
used. Orthodontists and orthodontic associations should
attempt to better guide patients looking for information to
credible online resources and should use effective search
engine optimization to effectively target their patient
base.
40
Introduction
The extraction debate has existed in the field of
orthodontics almost since the origin of the specialty
itself.1,2 Over one hundred years later, orthodontists
continue to dispute the extent to which extractions are
necessary for successful treatment.3 With the advance of the
Internet Age, this debate has since extended to the web to
be viewed by orthodontists, dentists, and patients alike.
With patients taking greater charge of their healthcare
decisions and performing their own research, the internet
is often considered a valuable information source. However,
this information could also be detrimental to the patient
if it is not reliable and supported by evidence-based
research and findings.
It has yet to be decided what the ideal orthodontic
treatment choice should be in regard to orthodontic
extractions. While extractions are employed by most
orthodontists, the frequency with which they are
recommended varies widely – from a low of 30 percent to a
high of greater than 75 percent - and has changed over the
decades with the evolution of new philosophies and the
reemergence of past ideas.4 However, a certain group of
orthodontists and general dentists continue to advocate for
41
extremely low numbers of extractions, often using nonevidence-based claims to steer patients away from
extraction treatment. The majority of available research
shows that, when applied judiciously, extractions are part
of an appropriate treatment method and often the
recommended choice by the majority of orthodontists. With
this said, those practitioners (as well as general
dentists, previously or currently treated patients,
orthodontic product and appliance companies, etc.) who are
adamantly vocal about extractions being detrimental to
orthodontic treatment outcomes in almost all cases may be
providing a disservice to patients seeking information
concerning whether extractions may or may not be
appropriate for them.
This study investigated the nature of available
information about orthodontic-related extractions
specifically found on the internet. It assessed websites
discussing this topic and determined whether there was a
greater likelihood for a layperson seeking information to
find information in support of or against treatment with
extractions. In addition, the study evaluated what type of
website a layperson is most likely to find, whom is
authoring what type of information, and whether the
42
existing biases of the searcher altered the type of
information that they are most likely to find.
43
Methods and Materials
The terms “orthodontic extractions”, “braces
extractions”, “orthodontics without extractions”, “braces
without extractions”, “braces extractions good or bad”, and
“non-extraction orthodontist” were entered into the Google
search engine to compile the list of websites to be
surveyed and analyzed. In addition, the terms “braces” and
“orthodontics” were searched to serve as a control of sorts
to set a baseline for the types of general information
available in regard to orthodontic extractions without the
bias of a directed search for information on the particular
subject. Google was the search engine of choice for this
study because it has consistently been ranked the #1 search
engine used throughout the world for several years, with
approximately 70% of the current global market share of all
completed searches.5,6
For each of the completed searches, web browser and
Google settings were optimized to limit location and
personalization bias in several ways.7 The Firefox web
browser was used in Incognito mode to avoid potential bias
created by cookies and cache that would be recorded and
stored during the search period. Also, for all searches,
the browser was signed out from all Google accounts and the
44
depersonalized Google link http://www.google.com/search
?q=%s&pws=0 was used by replacing the %s in the link
address with the words for each search term (ex.
http://www.google.com/search?q=orthodontic_extractions
&pws=0). In addition, Google search settings were changed
so that the search location would be for the entire United
States rather than precise location searching based on IP
address.
All searches were completed over a two day period and
the top 100 search results were recorded in ranked order
initially before any website evaluation was done to ensure
that their optimized ranking in the search engine results
did not vary during the time taken to complete website
analysis. Websites of interest for this study included any
websites that a potential patient or parent of a child
receiving treatment would find beneficial in a search for
information about orthodontics-related extractions. A full
list of exclusion criteria can be found in Appendix A.
The websites remaining after filtering for exclusion
criteria were evaluated and categorized by the type of
website, authorship, practice location and American Board
of Orthodontics certification where applicable, use of
references for any claims made, and positive or negative
45
stance on the practice of extractions for the purpose of
orthodontics. All classification categories and methods can
be found in Appendix B.
To fully and accurately evaluate the attributes of
each website (and to simulate the behavior of the average
internet user seeking information), the entire site was
evaluated when necessary to determine pertinent
characteristics such as author’s credentials, location,
board-certification, and extraction philosophy.
46
Results
Of the 800 websites assessed during this study, there
were 558 total website results after filtering for
exclusion criteria and, of those, 399 unique website
results across the 8 search queries. Some of the websites
counted as unique were subpages of website homepages that
were also found in the search results. In these cases, both
the homepage and all subpages were included and counted as
unique entries in the total study numbers. In addition,
several websites recurred across many of the search queries
and were also counted as a separate entry each time they
occurred when considering the total number of websites
analyzed (558) but included only once in the count (399) of
unique sites reviewed.
The eight search terms entered into the Google search
engine were grouped into three categories: neutral
searches, biased searches, and control searches.
Neutral
searches included the search terms “orthodontic
extractions”, “braces extractions”, and “braces extractions
good or bad”. Biased searches included the search terms
“orthodontics without extractions”, “braces without
extractions”, and “non-extraction orthodontics”. The
47
control searches were the search terms “braces” and
“orthodontics”.
Table 3.1 quantifies the number of search results that
fell under each category of website type for each search
query as well as in totality. The table also displays the
number of results that were analyzed per search query after
exclusion criteria were applied. The latter numbers will be
evident in Tables 3.2 and 3.3 as well.
Of all the combined search results, the largest
website type by far was orthodontic practice websites (241
out of 558, or 43.2%). This group was also the largest for
each of the individual searches, with the exception of the
search term “braces” for which orthodontic practice
websites tied with health resource website sites (without
“identified doctor” contributions) at 19 results each. Nonorthodontic practice websites were the second largest group
(11.5%) in the combined search results as well as for four
of the eight individual search terms.
Table 3.2 quantifies the number of search results that
fell under each type of authorship category for each search
query as well as in totality.
48
Table 3.1: Search results for each search term categorized
by website type
Neutral
Searches
Website Type
OE
Biased
Searches
Control
Searches
BE
BEGB
OWOE
BWOE
NEO
B
O
Total
Orthodontic practice
website
22
30
18
36
40
35
19
41
241
Orthodontic practice
blog
3
7
4
7
6
4
0
0
31
15
9
10
7
12
10
1
0
64
Non-orthodontic
practice blog
3
3
0
3
3
1
0
0
13
Health resource with
doctor contributions
3
6
5
4
6
2
0
0
26
2
4
12
1
5
1
19
5
49
3
13
7
2
9
1
0
0
35
Non-orthodontic
practice website
Health resource
without doctor
contributions
Community blog with
user-generated
content
Patient experience
blog
2
6
9
2
3
0
0
0
22
Professional
organization website
2
2
1
2
1
0
2
4
14
Product/alternative
philosophy website
4
3
5
4
7
4
8
1
36
Dental School
website
0
0
0
0
0
0
0
4
4
Doctor-produced
video
1
1
0
0
1
3
0
0
6
Patient/laypersonproduced video
1
2
1
1
1
0
0
0
6
0
0
0
0
0
0
1
1
2
1
2
0
3
3
0
0
0
9
Reference work
Other
Total
62
OE
88
72
72
97
"orthodontic
extractions"
BE
"braces extractions"
BEGB "braces extractions
good or bad"
OWOE "orthodontics
without extractions"
49
61
50
56
558
BWOE "braces without
extractions"
NEO "non-extraction
orthodontist"
B
"braces"
O
"orthodontics"
Orthodontists authored the majority of the content
analyzed. Their websites made up 50.7% of the total search
results and they were the predominant group for each of the
search terms. General dentists, pediatric dentists, and
oral surgeons made up the next largest group in total and
for each search. Patients and other laypeople authored 31
of the 558 websites (5.6%) and were represented in every
group of non-control search results except the “nonextraction orthodontist” group. Community-driven blog posts
also comprised a noteworthy percentage (6.6%) of the search
results, making up the third largest total number of sites.
Searches including the words “orthodontic(s)” or
“orthodontist” produced results mainly authored by
orthodontists or general dentists and very few sites
composed by other author identification classes (Table
3.2). Conversely, the searches using the word “braces” saw
more patient experience blogs, community-driven blogs, or
health resources with or without doctor contributions
(listed in the table as the category “several dental
professionals” or “unknown”) than the other search terms.
Nonetheless, the results in these cases were still
predominately authored by orthodontists and dentists.
50
Table 3.2: Search results for each search term categorized
by authorship
Neutral
Searches
Author
Identification
Orthodontist
OE
BE
Biased
Searches
Control
Searches
BEGB
OWOE
BWOE
NEO
B
O
Total
27
38
21
45
48
44
19
41
283
20
17
15
13
20
12
1
0
98
Several dental
professionals
2
5
4
2
6
1
1
1
22
Patient or
layperson
3
9
11
3
4
0
1
0
31
Community blog
with several
responders
3
13
7
3
10
1
0
0
37
3
2
1
3
1
0
9
6
25
1
0
0
2
3
1
9
2
18
0
0
0
0
0
0
0
4
4
1
1
2
0
1
0
0
0
5
2
3
11
1
4
2
10
2
35
88
72
72
97
"orthodontic
extractions"
"braces extractions"
"braces extractions
good or bad"
"orthodontics
without extractions"
61
BWOE
General Dentist
or other
specialty
Organization
Company
Dental School
Other*
Unknown
Total
62
OE
BE
BEGB
OWOE
51
50
56
558
"braces without
extractions"
NEO
"non-extraction
orthodontist"
B
"braces"
O
"orthodontics"
*Other = dental health
advocate, naturopath,
etc.
Extraction stance was grouped into three broader
categories as well: general support, lack of support, and
neutral opinion. The stances recorded as general support
included “support” and “support with bias”. The lack of
support group included the classifications “non-extraction”
or “mixed opinion”. The neutral opinion group was comprised
of the categories “neutral” and “no mention”.
Table 3.3 quantifies the number of search results that
took each type of stance toward the practice of orthodontic
extractions for each search query and in totality.
The number of search results showing general support for
extractions (support or support with bias) was relatively
consistent throughout the neutral and biased search queries
and was twice as high in total as the total number of
results not supporting extractions (mixed opinion or nonextraction). This ratio is also demonstrated in Table 3.4.
In addition, within each search group, the number of
websites with a positive extraction stance was
approximately twice the sites with a negative opinion, with
the exception of the “non-extraction orthodontist” group.
That group actually saw more non-extraction websites than
those supporting extractions and the ratio was closer to
1:1 (but in favor of the negative).
52
Table 3.3: Search results for each search term categorized
by extraction stance
Neutral
Searches
OE
BE
BEGB
Support
Support
(bias)
Mixed
opinion
Nonextract.
Neutral
No
mention
Total
Biased
Searches
OWOE BWOE NEO
Control
searches
B
O
Total
34
48
27
32
32
23
9
19
224
3
7
11
15
26
3
1
1
67
5
10
7
5
12
1
1
0
41
15
15
11
16
23
30
0
0
110
3
6
9
3
1
3
0
0
25
2
2
7
1
3
62
88
72
72
97
OE
"orthodontic
extractions"
BE
"braces extractions"
BEGB "braces extractions
good or bad"
OWOE "orthodontics
without extractions"
91
1
39
36
61
50
56
558
BWOE "braces without
extractions"
NEO "non-extraction
orthodontist"
B
"braces"
O
"orthodontics"
The searches biased toward non-extraction accordingly
saw more negative extraction stance classifications (mean =
29 results per search) than the neutral search terms (mean
= 21 results per search).
For the controls (“braces” and “orthodontics), the
extraction stance results were overwhelmingly split into
just two groups, support or no mention at all. There was
53
only one result expressing a negative stance (mixed
opinion) out of the 106 websites comprising these two
groups.
There were more mixed opinion classifications for the
search terms including the word “braces” (“braces
extractions”, “braces without extractions”, and “braces
extractions good or bad”) than for the other search terms
using the word “orthodontics”. The majority of the websites
classified as mixed opinion were community-driven blog
posts.
The counts for the “braces without extraction” group
showed somewhat of an anomaly in comparison to the other
searches in the high number of websites categorized as in
support with a bias to extractions (26). These websites
were mainly orthodontic practice websites.
Table 3.4 quantifies the number of unique search
results per website type that took each type of stance
toward orthodontic extractions. In addition, the table
shows the total number of search results of the 399 unique
websites to fall under each category of website type. This
is in contrast to Table 3.1, which shows the specific
number of instances within and across all of the search
54
Table 3.4: Stance on orthodontic extraction categorized by
website type
Lack of
Support
General Support
Support
Support
(bias)
Mixed
opinion
Orthodontic
practice website
84
39
0
Orthodontic
practice blog
11
4
Non-orthodontic
practice website
22
Non-orthodontic
practice blog
Neutral Stance
Neutral
No
mention
Total
18
3
41
185
0
1
0
0
16
3
0
22
0
6
53
3
0
0
3
0
0
6
13
0
5
0
0
0
18
11
1
1
1
2
19
35
6
0
13
3
1
0
23
1
0
2
2
9
0
14
3
0
0
0
1
4
8
1
2
0
8
1
9
21
Dental School
website
1
0
0
0
0
3
4
Doctor-produced
video
2
0
0
3
1
0
6
Patient/layperson
-produced video
0
0
0
1
1
0
2
1
0
0
0
0
1
2
0
1
1
2
2
0
6
159
50
22
64
21
83
399
Website Type
Health resource
with doctor
contributions
Health resource
without doctor
contributions
Community blog
with user-gen.
content
Patient
experience blog
Professional
organization
website
Product/alt.
philosophy
website
Nonext.
Reference work
Other
Total
209
86
55
104
queries, whereas the data in this table takes each specific
search result into account only once regardless of the
number of times it appeared. The groupings in Table 3.4 are
also further consolidated into the broader categories of
extraction stance mentioned previously.
The most frequent website type of all the unique
search results, similar to the results seen in Table 3.1,
was the orthodontic practice website, making up 185 of the
399 results (46.4%). The second most common type of website
seen was the non-orthodontic practice website (13.3%). When
both categories of health resource websites (those with and
without “identified doctor” contributions) are combined,
they make also make up a substantial proportion of content,
equaling the non-orthodontic practice numbers (53 out of
399 websites, or 13.3%). Following this group, communitydriven blogs comprise a notable 5.7% of unique search
results.
Orthodontic and non-orthodontic practice websites make
up the majority of the content supporting the use of
extractions for orthodontic purposes. On the other hand,
these sites also make up the majority of search results
promoting non-extraction, with community-driven blogs being
the only other significant contributor. Most importantly,
56
while orthodontic practice websites are considerably skewed
in favor of the promotion of extractions, non-orthodontic
practice websites have almost as many sites in opposition
to extractions (22) as there are in support of the practice
(25).
Behind orthodontic and dental practice websites,
health resource websites were the greatest supporters of
extraction treatment, probably due to their authorship by a
similar constituency. There were no websites of this kind
solely promoting non-extraction treatment. Nevertheless,
several webpages were of mixed opinion, with some doctors
stating that extractions were acceptable and others
claiming that they were detrimental to the patient.
Similarly, community-driven blog posts displayed several
mixed opinions of this kind. However, this type of website
leaned more toward non-extraction treatment.
Table 3.5 quantifies the number of unique search
results that fell under each category of extraction stance
based on author credentials. The table also shows the total
number of websites from the 399 unique search results that
fall within each authorship category.
57
Table 3.5: Stance on orthodontic extraction categorized by
website authorship
General Support
Author
Identification
Orthodontist
Lack of Support
Support
Support
(bias)
Mixed
opinion
Nonext.
Neutral Stance
Neutral
No
mention
Total
98
43
1
23
4
41
210
Dentist or
other
specialty
28
4
0
31
1
6
70
Dental
professionals
9
0
5
0
0
0
14
Patient or
layperson
1
0
2
4
10
0
17
Blog - several
responders
6
0
13
3
1
0
23
4
0
0
0
3
10
17
1
2
0
0
0
10
13
1
0
0
0
0
3
4
0
0
0
2
0
0
2
11
1
1
1
2
13
29
159
50
22
64
21
83
399
Organization
Company
Dental School
Other*
Unknown
Total
209
86
104
As stated previously, there were almost twice as many
total search results in general support of extractions than
there were lacking support of the practice. Most of the
websites supporting extraction use were written by
orthodontists. Dentists were the second largest group for
extraction support, but there was a large discrepancy
between the number of orthodontist-authored sites versus
those written by dentists and other specialists. The
58
websites partially or largely opposing extractions were
predominantly authored by a relatively even mix of dentists
(31 websites) and orthodontists (24 websites). However,
proportionally speaking, dentists were much more likely (31
out of 70, or 44.3%) to promote non-extraction treatment
than orthodontists (24 out of 210, or 11.4%). Furthermore,
while orthodontists were much more likely to fall into the
general support category than the lack of support group
(141 extraction to 24 non-extraction), general dentists
were split approximately evenly between those that
supported and those that opposed extraction treatment (32
extraction to 31 non-extraction). This is similar to the
results seen in Table 3.4.
Of the websites authored by patients or laypeople,
though the sample size was small, this group was much more
likely to be opposed in some capacity to orthodontic
extractions than in support of the practice (1 supporter
versus 6 of mixed opinion or for non-extraction). The
majority of their entries (10 websites), however, were
determined to be neutral.
As previously demonstrated in Table 3.4, communitydriven blogs with several responders tended to most often
be of mixed opinion. Half as many websites were in full
59
support of extractions as those that had a mix of negative
and positive posts.
The top ten search results for each search term were
grouped by category (neutral searches, biased searches, and
control searches) and recorded in Tables 3.6, 3.7, and 3.8.
In addition, the top three search results per search term
were listed based on extraction stance in Table 3.9,
website type in Table 3.10, and authorship in Table 3.11.
Tables 3.6 and 3.7 establish that, for any given search on
this topic, one is likely to find a variety of beliefs
within the top results returned. With the exception of the
search term “orthodontic extractions”, every search query
produced at least 3 websites in the top ten search results
that oppose extractions in some way. More significantly,
within the top three search terms (Table 3.9) - the sites
most likely to be accessed for any given search8 - there is
at least one instance of a search result in opposition of
extraction treatment for every search query.
The results for the biased search terms in
particular (Table 3.7 and Table 3.9) demonstrate that, when
the search term is worded in a leading manner, there is an
even higher likelihood that a website within the top search
60
Table 3.6: Top ten search results per neutral search term
Neutral Searches
"orthodontic
extractions"
1
2
3
4
5
6
7
8
9
10
Support
Support
Mixed opinion
Support
Support
Support
"braces
extractions"
"braces
extractions
good or bad"
Mixed opinion
Support
Support
Support
Support
Non-extraction
Neutral
Mixed opinion
Support
Support
Support
Mixed opinion
Support
Support
Support
Support
Support
Support
Mixed opinion
Non-extraction
*Bolded entries represent search results that took a
negative stance (lack of support) on the practice of
orthodontic extractions. Dashes represent a search result
that was not included in the study due to exclusion
criteria.
Table 3.7: Top ten search results per biased search term
1
2
3
4
5
6
7
8
9
10
"orthodontics
without
extractions"
Biased Searches
"braces
without
extractions"
"nonextraction
orthodontist"
Support
Non-extraction
Non-extraction
Mixed opinion
Support
Support
Support
Support
Support
Support
Mixed opinion
Non-extraction
Support
Support (bias)
Support
Non-extraction
Support
Support
Support
Non-extraction
Support
Support
Non-extraction
Non-extraction
Non-extraction
*Bolded entries represent search results that took a
negative stance (lack of support) on the practice of
orthodontic extractions. Dashes represent a search result
that was not included in the study due to exclusion
criteria.
61
Table 3.8: Top ten search results per control search term
Control Searches
"braces"
1
2
3
4
5
6
7
8
9
10
Support
No mention
No mention
No mention
No mention
No mention
No mention
No mention
No mention
"orthodontics"
No mention
No mention
No mention
No mention
No mention
No mention
No mention
Support
-
*Dashes represent a search result
that was not included in the study
due to exclusion criteria.
results will be of a negative persuasion. In comparison to
the control searches (Table 3.8) where the vast majority of
the search results are neutral (the topic is not even
mentioned), all of the biased search terms produced top-ten
negative results to the tune of 30% or greater and two of
the three queries returned two non-extraction websites in
the top three results. The remaining search term (“nonextraction orthodontist”) returned non-extraction websites
for two-thirds (4 out of 6) of the top ten results
including, most importantly, the #1 result.
62
Control
Biased
Neutral
Table 3.9: Extraction stance of the top three search
results per search term
#1
Google Search Ranking
#2
OE
Support
Support
Mixed opinion
BE
Mixed opinion
Support
Support
BEGB
Support
Mixed opinion
Support
OWOE
Support
Non-extraction
Non-extraction
BWOE
Support
Mixed opinion
Non-extraction
NEO
Non-extraction
Support
Support
B
Support
No mention
No mention
O
No mention
No mention
No mention
OE
"orthodontic
extractions"
BE
"braces extractions"
BEGB "braces extractions
good or bad"
OWOE "orthodontics
without extractions"
#3
BWOE "braces without
extractions"
NEO "non-extraction
orthodontist"
B
"braces"
O
"orthodontics"
Table 3.10 demonstrates the variation in website type
that patients may come across and are most likely to access
when performing a search similar to those of this study.
The results for the neutral and biased search terms show
that the top sites may not necessarily be authored by a
credible source (for the sake of this study, an
orthodontist or dentist). For five of the six search
63
Table 3.10: Website type of the top three search results
per search term
Google Search Ranking
Control
Biased
Neutral
Search Term
#1
#2
#3
OE
Orthodontic
practice website
Health resource
with doctor
contribution
Patient
experience blog
BE
Patient
experience blog
Orthodontic
practice blog
Health resource
with doctor
contribution
BEGB
Orthodontic
practice website
Community-driven
blog post with
user-generated
content
Orthodontic
practice website
OWOE
Orthodontic
practice blog
Non-orthodontic
practice blog
Product/
alternative
philosophy
website
BWOE
Orthodontic
practice blog
Community-driven
blog post with
user-generated
content
Non-orthodontic
practice blog
NEO
Non-orthodontic
practice blog
Orthodontic
practice website
Orthodontic
practice blog
B
Reference
website (online
encyclopedia)
Health resource
website
Product/
alternative
philosophy
website
O
Reference
website (online
encyclopedia)
Professional
organization
website
Professional
organization
website
OE
"orthodontic
extractions"
BE
"braces extractions"
BEGB "braces extractions
good or bad"
OWOE "orthodontics
without extractions"
BWOE "braces without
extractions"
NEO "non-extraction
orthodontist"
B
"braces"
O
"orthodontics"
*Bolded entries represent search results of a website type considered
less credible than that produced by an orthodontist or other comparable
dental professional.
64
queries, of the top three prime spots, at least one
includes information authored by a patient, a doctor
pushing a self-invented product, or several laypeople in a
community blog. Along the same lines, Table 3.11 shows
similar results, with four of the six non-control search
queries having results written by patients or laypeople in
a community blog. Notably, two of the #1 spots for these
six queries are held by a patient and a non-extraction
dentist.
Sixteen of the 399 websites listed references to
support the claims made within the content. Of these sites,
10 of the websites were in support of or neutral to the
practice of extractions while 5 of the sites promoted nonextraction techniques. The remaining site was a communitydriven blog post in which one of the users provided
reference to support her belief that teeth should not be
extracted. However, other posts within this blog supported
extractions and the website was categorized as “mixed
opinion”.
Of the 180 pages authored by American orthodontists,
74 (41%) stated that they were Diplomates of the American
Board of Orthodontics. Of the doctors that were Diplomates,
34 of their webpages were categorized as “support” while 14
65
Table 3.11: Website authorship of the top three search
results per search term
Google Search Ranking
Control
Biased
Neutral
Search Term
#1
#2
OE
Orthodontist
Oral Surgeon
BE
Patient/
layperson
Orthodontist
BEGB
Orthodontist
Several
responders
Orthodontist
OWOE
Orthodontist
General Dentist
Orthodontist
BWOE
Orthodontist
Several
responders
General Dentist
NEO
General Dentist
Orthodontist
Orthodontist
B
Unknown
Unknown
Company
O
Unknown
Organization
Organization
OE
"orthodontic
extractions"
BE
"braces extractions"
BEGB "braces extractions
good or bad"
OWOE "orthodontics
without extractions"
#3
Patient/
layperson
Dental
professionals
BWOE "braces without
extractions"
NEO "non-extraction
orthodontist"
B
"braces"
O
"orthodontics"
*Bolded entries represent search results of a website type considered
less credible than that produced by an orthodontist or other comparable
dental professional.
were classified as “support with bias toward nonextraction”. One doctor’s page took a “neutral” stance.
Only 8 Diplomate websites were marked as “non-extraction”
and the remaining 17 did not mention extractions at all
throughout their website. Comparison of the number of
board-certified orthodontist in general support of
extractions (48) versus those that oppose the practice (8)
66
produced a ratio of 6:1 in favor of extractions. There was
only one board-certified orthodontist in the 74 pages
searched that included references to support their claims.
67
Discussion
The practice of extractions for orthodontic treatment
has been a source of serious controversy in the dental
community and greater community at large dating back to the
days of Angle and beyond. Despite the extensive history and
the drastic changes in trends and ideas that we have
witnessed over the past century4,9, a formal stance on
orthodontic-related extractions has yet to be established.
The purpose of this study was not to attempt to establish a
stance in either direction. Instead, the aim of the
investigation was to evaluate the ways in which this
controversy has translated over to the World Wide Web with
the continued evolution in today’s Digital Age of online
health care.
After applying the exclusion criteria to the 800
initial search results produced, two comprehensive lists
were compiled. The first, totaling 558 websites, included
every remaining search result. Duplicates were not removed
from this group in order to represent the frequency of
appearance of each website in the total analyzed search
results. This is significant because websites that appeared
more than once in the search results were more likely to be
viewed by the patients looking for information and,
68
consequently, the content of these websites would ideally
be more influential. For the second list, all duplicates
were removed leaving 399 unique websites. This smaller list
was compiled to better evaluate the characteristics of the
individual websites making up the content appearing in
these searches. Each result was looked at only once to
determine the real proportions of the attributes within
each category, irrespective of the number of times they may
appear across the search results. Therefore, the
information in Tables 3.1, 3.2, and 3.3 looks at frequency
of appearance or the odds that a searcher will view a
particular webpage while Tables 3.4 and 3.5 evaluate the
characteristics of the individuals and institutions
contributing to the larger information pool.
The search terms were grouped into categories based on
the suspected perspective of the searcher who would enter
those particular terms (Tables 3.1, 3.2, 3.3, 3.6, 3.7,
3.8, 3.9, 3.10, and 3.11). For example, the terms
categorized as neutral search terms (“orthodontic
extractions”, “braces extractions”, and “braces extractions
good or bad”) are Google searches that one would expect
from a patient or parent simply trying to find more
information about the recommended procedure. The biased
69
searches (“orthodontics without extractions” “braces
without extractions” and “non-extraction orthodontist”), on
the other hand, suggest a preconceived negative opinion
toward extractions or the desire of the patient to find a
way to avoid having extractions for whatever reason. The
patient may or may not think that extractions are
detrimental to their well-being but, nonetheless, seems to
be against having the procedure performed based on this
type of query. The two control searches (“braces” and
“orthodontics”) were included simply to have a baseline to
which the more directed search terms could be compared.
The search terms were also consolidated into larger
groups based on extraction stance (Table 3.4 and 3.5) in an
attempt to simplify the analysis of the data. Despite the
larger categories, little information was lost in this
merging of data because of how the sites were assigned,
again based on the perception of the patient performing the
hypothetical search. While the search results categorized
as pro-extraction (support) were easily delineated, the
results put into the category of support with bias toward
non-extraction tended to state that they strove for nonextraction treatment whenever possible, adding a potential
layer of confusion for the reader. However, to be
70
categorized in this group, an obvious caveat had to be
provided that extractions may be performed in some cases if
necessary. This clearly suggests to the reader that the
practitioner does recommend extractions in some cases and
that extractions may be a possibility. One can further
extrapolate from this that the author of the content must
believe in the practice of extractions at least to some
extent for them to recommend such treatment, thus
justifying the categorization into the larger group of
general support for extractions.
Similarly, websites categorized as mixed opinion would
likely give a perception to the reader that extraction
treatment is potentially harmful. The majority of the
websites marked as mixed opinion were community-driven blog
posts with content generated by several users, usually
laypeople. While, in several of these message boards, there
were pro-extraction opinions expressed, the negative
opinions and warnings intermixed with these comments would
probably be enough to cast doubt about the safety of this
procedure to the uninformed reader. Consequently, these
search results were labeled as lacking support for
orthodontic extractions and grouped along with the clearcut non-extraction websites.
71
While discussing websites lacking support for
orthodontic extractions, it is prudent to point out that,
although a website may have been classified as nonextraction for the purposes of this study, this does not
mean that the author of that content necessarily subscribes
solely to a non-extraction philosophy in actuality.
Instead, the categorization was made simply based on the
assumed perceptions that the uninformed reader is likely to
have while evaluating each search result.
Paradoxically, almost every orthodontist practices
“non-extraction treatment” for a good majority of their
patients, over 70% on average according to Profitt’s
estimates4,9. As such, including information on nonextraction treatment does not inevitably make an
orthodontist an opponent of extractions. However, if it is
not clear from their website that other treatment methods
are also used, this might lead the patient to assume that
the author was a non-extractionist. In a similar fashion,
websites that seemed likely to lead the reader to such a
conclusion based on the presentation of its content were
marked as non-extraction for this study.
Several practitioners intentionally toy with these
easily manipulated perceptions of the uninformed consumer,
72
strategically marketing themselves in a way that leads
consumers to believe that extractions will not be proposed
solely for the purpose of getting more patients through the
door. By displaying that they practice non-extraction
techniques but conveniently not mentioning on their website
other treatment practices utilized, practitioners avoid
scaring patients off who may be avoiding extraction
treatment due to misinformation, fear, or any other reason.
This has now become an effective method for orthodontists
and dentists alike to boost their treatment numbers. The
technique has probably been most commonly seen and
successfully executed in the marketing of Damon appliances
(Ormco Corporation, Orange, CA), now mistakenly referred to
by some patients as “non-extraction braces”.
Another factor to note from the results of the study
was the type of bias that existed or became evident based
on the linguistic characteristics of the search query
entered. Search results were clearly affected by the
inherent biases and wording of the particular search term
used. For example, while neutral search terms were likely
to give a plethora of search results of varying opinion,
the study showed that biased searches tended to be a selffulfilling prophesy, producing more negatively biased (non-
73
extraction) results than the neutral searches or controls.
Further, in the control searches, while there was general
mention of extractions in several of the websites returned,
there was no mention whatsoever of non-extraction
treatment, which was markedly different than the findings
of the targeted searches. Additionally, searches using more
colloquial language like the term “braces” returned a
greater number of unreliable websites – more community
blogs or health resources written by patients or laypeople
– than those including the more formal term “orthodontics”.
This further demonstrates the biases formed by differing
search terms and shows that targeted search terms do have
an effect on what the searcher will find.
Despite these previous factors mentioned, perhaps the
most important concept to note and factor into the analysis
of the data gathered in this study is that, regardless of
sheer numbers for any of the groups, any other demographic
can easily be more influential in the real world of online
searching due to the position in the search rankings of the
sites returned. Research has shown that people using search
engines such as Google, with a default setting of ten
results per page, rarely get past the first page of
results.8,10-13 Table 3.128 shows the results of a study
74
Table 3.12: Google click distribution and amount of time
spent per website according to search result position8
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
% of clicks
56.36
13.45
9.82
4.00
4.73
3.27
0.36
2.91
1.45
2.55
% Time Spent
28.43
25.08
14.72
8.70
6.02
4.01
3.01
3.68
3.01
2.34
completed at Cornell University that was able to quantify
the relative number of clicks and amount of time spent per
website for the average search query. The study found that
56.4% percent of searchers will click on the first link
displayed and that 83% of total clicks will be distributed
between the top 5 search results. With 98.9% of clicks per
search query being distributed between the top ten results,
this leaves only 1.1% of the clicks for a given search to
be distributed between the remaining hundreds of thousands
or possibly millions of search results remaining.
Obviously, the odds of being viewed for websites ranked
anything greater than #10 are slim to none. Furthermore,
the location of a site within this first page of results
plays a significant role in the likelihood that the
searcher will chose to view the content.
75
Based off of these statistics, while most of the data
for this study was significantly skewed toward authorship
by orthodontists and support for orthodontic extractions,
general dentist and patient contributions were accordingly
more influential than one would assume solely from the
numbers due to their frequency and position within the top
ten search results (Table 3.10 and 3.11), the sites most
likely to be accessed by the searcher.
This is the reason why search engine optimization has
become such a major topic in recent years. With everything
from electronics to clothing to buying groceries headed in
the direction of online shopping, it is important to all
business owners to work their way up the search rankings.
Search engine optimization - the strategies and techniques
employed to increase a website’s position in search engine
rankings – is not influenced however by the quality,
reliability, or validity of the content of a webpage but,
rather, by factors like the number of hits that site has
gotten in the past11 or the use of particular keywords.
This means that is very easy and also extremely likely
for less credible sites such as community blogs or those
produced by patients to be listed higher in the rankings
than more reliable sites (doctor-authored content) and, as
76
a result, they may be more likely to be viewed by the
searcher. In addition, the highly ranked websites
consequently are not guaranteed to be (and usually aren’t)
the most valuable to the searcher nor are they promised to
contain the best or most reliable content,11 as was
demonstrated in the data gathered in this study (Tables
3.6, 3.7, 3.8, 3.9, 3.10, and 3.11).
Along similar lines, it is interesting to note the
large proportion of gathered data that was authored by
general dentists and other practitioners. Although it has
been a known fact for several years that dentists are
increasingly becoming more and more involved with
orthodontics, it was surprising to see that dentists were
attaining prime search result real estate, filling several
of the top search result slots and even achieving the
number one spot for one of the search queries (Tables 3.10
and 3.11).
Moreover, while the issue of orthodontic treatment
provided by general dentists cutting into the orthodontic
market share has been a popular discussion topic of late,
it seems that the greater issue may be the misinformation
that is being perpetuated predominately within their
demographic according to Tables 3.4 and 3.5. Not only are
77
they more likely based on this data to endorse nonextraction treatment but the promotion of this philosophy
is often accompanied by unsubstantiated claims on their
websites that extractions will damage the face, ruin the
smile, cause TMJ issues or sleep apnea, etc.
Whether this is an attempt to have an advantage over
orthodontists that may suggest extractions or simply a lack
of orthodontic education and knowledge of the literature,
these general practitioners are pushing claims that are not
supported by any evidence. This is detrimental to both the
patient, who may ultimately receive a less-than-ideal,
unstable result, as well as to the orthodontists who are
subsequently doubted by patients and accused of causing
harm for prescribing the alternative treatment despite the
practice being supported by decades of literature.
Community-driven blogs with user-generated content
tend to pose a similar issue. These blog sites provide a
place for people, usually mothers of young children, to ask
questions and seek the advice of their peers. However, the
majority of contributors have little orthodontic knowledge
other than the treatment that their children have received
or the outdated practices that they themselves underwent as
children several years or decades ago. In addition, many
78
internet users only seek out these types of resources once
they have had a bad experience and would like to alert
others to their misfortune. Consequently, the potential for
the spread of misinformation is high in these types of
forums and, to make matters worse, this unreliable content
is often ranked highly in the search results due to the
number of responders and hits per post, making it ever more
likely to be viewed and redistributed further.
When community blogs are combined with patient
experience blogs (similarly authored by laypeople with
little orthodontic knowledge outside of their own
experiences), this collective group comprises almost 10% of
the total search results evaluated. According to Tables 3.4
and 3.5, both of these groups are more than twice as likely
to express an opinion opposing orthodontic extractions than
one in support of the practice. At 10% of the total
results, this means that, even before factoring in search
engine optimization and click distribution, there is a one
in ten chance that a patient clicking on a search result at
random will be receiving information and medical advice
from a patient or other group of uninformed laypeople that
is most likely going to express a negative opinion solely
because of personal experience and not the facts. As
79
demonstrated in Tables 3.10 and 3.11, these sites often
show up in the top ten search results, drastically
increasing the likelihood that sites of this kind will be
viewed8,10-13 (Table 3.12).
Many studies10,11,14-17 have suggested that it is the
responsibility of the orthodontist (or any other medical
provider) to guide patients in their pursuit of further
information rather than leaving them to potentially resort
to these and other less credible online resources. By
better informing patients with accurate, evidence-based
opinions - both online and in person - and directing them
to validated, trustworthy resources with information
supported by literature when they desire more information,10
the need for a potentially unreliable second opinion (often
found on the internet) may be avoided. This, in turn, will
help to lessen patient confusion and the spread of
misinformation.
Orthodontists may contribute further in this regard by
not only guiding but also educating their patients,
teaching them to consider things like the ownership and
purpose of the site, availability and credibility of
sources, contact information, currentness of the content,
etc. when evaluating online medical resources.14,18
80
Ultimately, it is important for the orthodontist to know
what information is available to their patients so that
they can better steer them toward information that is
worthwhile and reliable.14
Additionally, orthodontists may want to focus more,
when constructing or updating their own websites, on techsavvy concepts like search engine optimization and blogging
so that they can start to reclaim more of these top spots
and help to disseminate more reliable information than that
being spread by other demographics like the general
dentists, community blogs, or patient websites. In
addition, as discussed previously, orthodontists should
understand when creating their websites that higher-level
or more scientific terms could prevent them from showing up
in search results, regardless of the quality of the
information they provide. It is important to write to the
level of the patient or at least use words more common to
their audience so that the websites will be picked up more
effectively in their patients’ targeted search queries.
It is also interesting to note that no American
orthodontic organizations came up in any of the targeted
search results. The American Association of Orthodontists
(AAO) patient websites (www.braces.org and
81
www.mylifemysmile.org) appeared only one time within the
600 targeted search website results returned and this lone
instance was ranked at #96 for that search query.
The
American Board of Orthodontists (ABO) patient website
(www.americanboardortho.com/public) did not appear at all.
On the contrary, however, the British Orthodontic Society’s
webpage (http://www.bos.org.uk/ public-patients-home)
showed up in four different targeted search queries and
appeared in the top ten results for two of these searches.
Furthermore, even if a patient was to go to the AAO or
ABO websites directly, none of them mention whether
extractions - or non-extraction treatment for that matter are a supported and approved treatment modality. As the
official national orthodontic associations, whose roles are
to advocate and establish the standards for the profession,
these websites should be the premier source and first
option that patients can turn to for trustworthy
information about all orthodontic topics and concerns.
Especially considering the most recent national marketing
campaigns for both the AAO and ABO, these organizations
should have a markedly better online presence. Their
websites should be updated to not only be more accessible
and conspicuous to the average internet user, requiring
82
improved search engine optimization, but also to better
serve as a comprehensive source of information for the most
common orthodontic topics - especially controversial ones
like extraction treatment - so that patients seeking
information do not have to resort to less valid resources.
Along these lines, it may be beneficial for
professional organizations such as the American Association
of Orthodontists, the American Board of Orthodontists, and
the American Dental Association to take a public stance most appropriately neutral - in regard to the practice of
extractions for orthodontic purposes. This could be
accomplished with something as simple as the provision of a
list of recognized techniques to address crowding and other
bite issues on these associations’ patient information
websites, much like what has been done on the webpage of
the British Orthodontic Society. While it would be
inappropriate to state that any one treatment is better
than another given that each patient’s circumstance is
unique, a public statement by the authoritative bodies
recognizing extractions, among other treatments, as a valid
treatment when used appropriately would help to correct
misperceptions on both the side of the patient and the
practitioner.
83
Conclusions
The majority of the information found was authored by
orthodontists and supported the practice of orthodontic
extractions. However, the study found that general dentists
heavily promote non-extraction treatment and their content
was just as likely to be viewed as orthodontist-produced
content due to their position in the search result
rankings. In addition, the type of search results returned
for a particular query is affected by the bias and language
choice of the particular search term used. Orthodontists
and orthodontic associations should attempt to better guide
patients looking for information to credible online
resources and should use effective search engine
optimization to effectively target their patient base.
84
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Bernstein L. Edward H. Angle versus Calvin S. Case:
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Burrow SJ. To extract or not to extract: a diagnostic
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Proffit WR. Forty-year review of extraction
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2011/02/ google-click-distribution-how-important-isnumber-one-position/. Accessed on September 21, 2014.
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treatment planning: limitations, controversies, and
special problems. In: Proffit WR, Fields HW, Sarver
DM, editors. Contemporary orthodontics. 4th ed. St.
Louis: Mosby; 2007. p. 276-84.
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APPENDIX A: FULL LIST OF EXCLUSION CRITERIA
Exclusion criteria included all of the following:
1. Websites not related to the clinical practice of
orthodontics in any capacity;
2. Websites (other than orthodontic practice sites)
that discuss other aspects of orthodontics but do
not directly mention orthodontic extractions;
3. Websites that only mention extractions performed for
purposes other than orthodontics (ex. wisdom tooth
extractions, extractions due to caries, etc.)
4. Journal articles or abstracts;
5. Websites specifically targeting or written for
dental professionals (ex. dental journals,
newspapers, magazines, professional blogs;
scientific websites; etc.);
6. Company, organization, or university webpages
without a section discussing treatment-related
information for patients;
7. Educational websites, including dental professional
education and courses (ex. interactive medical games
for children, orthodontic continuing education
websites, etc.);
87
8. Websites discussing insurance options and other
benefits for orthodontic treatment;
9. Websites not written in English; and
10.
Non-functioning webpages.
88
APPENDIX B: CLASSIFICATION METHODS AND CATEGORIES
Website Type Categories
Table B.1: Classifications used to assign website type
Website Type
Description
Orthodontic
practice
website
A website created for the purpose of marketing the
services provided by an orthodontic practice. For the
purposes of this study, this type of website is
assumed to be authored by the orthodontist.
Orthodontic
practice blog
A website created in blog format that is published in
conjunction with an existing orthodontic practice
website or as a standalone idea-sharing page
specifically mentioning orthodontics. This type of
website must be targeted specifically toward informing
the patient, NOT other dental professionals. This type
of website is written by the orthodontist and is
clearly updated at regular intervals.
Nonorthodontic
practice
website
A website created for the purpose of marketing the
services provided by a dental practice specializing in
a field other than orthodontics, (including but not
limited to general or cosmetic dentistry, pediatric
dentistry, or oral surgery). This website must clearly
state that it provides orthodontic services and must
also include patient information specific to
orthodontic treatment. For the purposes of this study,
this type of website is assumed to be authored by a
general dentist unless clearly stated otherwise.
Nonorthodontic
practice blog
A website created in blog format that is published in
conjunction with the website of an existing dental
practice specializing in a field other than
orthodontics (including but not limited to general or
cosmetic dentistry, pediatric dentistry, or oral
surgery) or as a standalone idea-sharing page
specifically mentioning orthodontics. This type of
website must be targeted specifically toward informing
the patient, NOT other dental professionals. This type
of website is written by a dentist or other nonorthodontic specialist and is clearly updated at
regular intervals.
Health
resource with
doctor
contributions
Any website made for the purpose of providing general
patient health information (may or may not be specific
to dentistry) where much of the content is provided by
identified and verified doctors. This type of website
often has contributions from several dentists or
orthodontists. For the purposes of this study, this
type of website is assumed to be authored by several
dental professionals.
89
Table B.1: Continued
Website Type
Description
Health
resource
without doctor
contributions
Any website made for the purpose of providing general
patient health information (may or may not be specific
to dentistry) that does not specify the identity
and/or credentials of the author. For the purposes of
this study, the author of this type of website is
marked as unknown.
Community blog
with usergenerated
content
Any blog post where the initiator of the post has
posed a question in regard to orthodontic extractions
and several users (laypeople or doctors) have
commented in response to this question. For the
purposes of this study, the author of this type of
website is marked as several responders.
Patient
experience
blog
Any website written by a patient that has undergone or
is currently in orthodontic treatment for the purpose
of sharing knowledge and experiences with other
potential or current patients. For the purposes of
this study, the author of this type of website is
marked patient/layperson.
Professional
organization
website
A website made for the purpose of providing
information to the members of an organization or
patients/laypeople seeking the services of the
organization.
Product/
alternative
philosophy
website
Any website made by a company or individual for the
purpose of selling an orthodontically-related product
or pushing an orthodontic philosophy that is not
currently a commonplace practice for the majority of
practicing orthodontics.
Dental School
website
Any website made for the purpose of advertising
services provided by a dental school clinic that
includes patient information specific to clinical
orthodontics.
Video created
by doctor
A video posted to YouTube or another video hosting
website that is clearly associated with or produced by
an orthodontist or dentist.
Video created
by patient
A video posted to YouTube or another video hosting
website that is clearly associated with or produced by
a patient or layperson.
Reference work
Any online reference material (ex. Wikipedia).
Other
Any website that does not fit into the previously
defined categories but that includes information
pertinent to the patient or parent searching for
information (ex. news story transcript, patient
advocate website, orthodontic practice Facebook/Yellow
Book page, etc.).
90
Extraction Stance Categories
The stance of each website on the practice of extractions
was assigned according to the following categories:
1. Support
a. The author states that extractions are an
acceptable treatment option with or without the
stipulation of appropriate or judicious use; or
b. The author displays cases for which they have
extracted teeth for treatment; or
c. The author states that they will perform
extractions for the purpose of orthodontic
treatment carried out by themselves or another
practitioner.
d. Examples:
i. “Removing teeth is sometimes required to
achieve the best orthodontic result.
Straight teeth and a balanced facial
profile are the basic goals of
orthodontics. However, because new
technology has provided advanced
orthodontic procedures, removing teeth is
not often necessary for orthodontic
treatment.”
ii. “If your teeth are severely crowded
(because your mouth is too small to
properly accommodate all of them) — or if
you have impacted teeth (teeth that are
trapped beneath the gum line by other
teeth) — then extraction may be necessary.
In the case of younger patients, early
treatment may make extraction
unnecessary.”
2. Support with a bias toward non-extraction treatment
a. The author states that they avoid extractions
whenever possible or have a preference for nonextraction treatment but will prescribe
extractions only in severe cases, or
b. The author states that they use appliances that
usually prevent the need for extraction except
in rare cases.
c. Example: “Our office's treatment philosophy is
very conservative, and we do make every effort
to avoid extraction. However, for severe
crowding and severe jaw discrepancy, extraction
may be required.”
91
3. Neutral - The author mentions orthodonticallyrelated extractions but does not claim a specific
stance or demonstrate a bias toward the subject in
either direction.
4. Mixed opinion – One or several authors (in the case
of community-driven blog posts) make statements both
for and against the practice of extractions within
the same webpage.
5. Non-extraction
a. The author states that they do not use
extractions as a treatment option or that they
follow a non-extraction philosophy with no
mention of extractions even in rare cases; or
b. The author states that extractions are
detrimental in some way to the well-being of
the patient and should not be utilized in
treatment; or
c. The author prominently promotes non-extraction
treatment on their website (with the dedication
of an entire section or page to non-extraction
treatment or including the phrase “nonextraction” in their marketing headings) with
no mention of other treatment practices; or
d. The author strongly emphasizes that teeth were
not extracted in any displayed cases in a way
that suggests a bias to this treatment
philosophy.
6. No mention – The website is related to orthodontics
in some way but does not mention extractions in any
form throughout the entire content of the site.
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Authorship Categories
The following categories were used to assign authorship*:
-
Orthodontist
Dentist or other specialty
Several dental professionals**
Patient or layperson**
Several responders**
Organization
Company
Dental school
Other**
Unknown*
*When authorship was not immediately clear, assignment was
made based on the most reasonable and educated deduction of
the author’s credentials. In cases where there was no valid
or reliable way to deduce a classification, authorship was
classified as unknown.
**See descriptions of Website Type Categories (Appendix B)
for appropriate assignment of these authorship categories.
Board-Certification Determination
Board-certification was determined for all websites whose
authors are orthodontist practicing in the United States.
Authors were credited as board certified if they directly
stated that they were board-certified or a Diplomate of the
American Board of Orthodontists within the content of their
website or they displayed the American Board of
Orthodontics seal somewhere on their website.
93
Use of References Determination
Classification for the use of references was determined by
examining any content pertaining to the topic of
orthodontic-related extractions throughout the entirety of
the website for the presence of cited literature. Reference
usage was defined as the listing of any citations of
articles from orthodontic, dental, and medical journals or
other scholarly articles or papers in reference to claims
made in the website content.
94
APPENDIX C: SEARCH RESULTS PER SEARCH TERM
Table C.1: Unfiltered Search Results for the Search Term
“orthodontic extractions”
Search
Ranking
Website Address
1
2
http://www.centuryorthodontics.com/extractions...why.doc
http://www.deardoctor.com/inside-the-magazine/issue19/tooth-removal-for-orthodontic-reasons/
3
4
5
http://www.archwired.com/Extractions_for_Braces.htm
http://www.ncbi.nlm.nih.gov/pubmed/2589256
http://www.inner-smiles.com/ortho-news-articles/orthodonticextractions
http://www.inner-smiles.com/orthodontic-services-coloradosprings/orthodontic-extractions
http://www.slideshare.net/irfanzunzani/extractions-inorthodontics-ug
http://www.nature.com/bdj/journal/v196/n4/full/4810979a.html
http://www.progressinorthodontics.com/content/14/1/47
http://www.gregjorgensen.com/blog/2012/05/will-having-teethremoved-ruin-my-face/
http://www.scielo.br/scielo.php?script=sci_arttext&pid=S2176
-94512012000200025
http://www.scielo.br/pdf/dpjo/v15n3/en_17.pdf
https://www.smilecolumbia.com/pre-orthodontic-extractionsis-there-a-better-way/
http://www.youtube.com/watch?v=Doud9-oYBcw
http://www.youtube.com/watch?v=zqX51OeXXlc
http://www.pupkindental.com/blog/post/child-star-nolangould-talks-about-tooth-extractions-orthodontictreatment.html
http://www.angle.org/doi/pdf/10.1043/00033219%281956%29026%3C0243%3AIACFEI%3E2.0.CO%3B2
http://orthocj.com/2009/04/extraction-choice-in-the-era-ofevidence-based-orthodontics/
http://onlinelibrary.wiley.com/doi/10.1111/j.18347819.2005.tb00353.x/pdf
http://www.veryniceteeth.com/index.php/patienteducation/extraction-vs-non-extraction
http://www.thetoothmover.com/crowding-extractions/
http://www.manhattanbridgeortho.com/orthodontic-treatmentplan-really-need-extract-teeth/
http://www.finellidds.com/procedures/pre-orthodonticextractions/
http://www.northsydneyorthodontics.com.au/extractionorthodon
tics.htm
http://www.harrington-ortho.com/extractions.html
http://www.realself.com/question/tooth-extraction-forbraces-40
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
95
Table C.1: Continued
Search
Ranking Website Address
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
www.researchgate.net/...orthodontic_extraction.../0c9605229.
.
http://www.dentalpedia.ca/treatments/extractions/
http://www.learnortho.com/docs/Ortho%20extractions%202007.pdf
http://claimingpower.com/reverse-extraction-orthodontics-isit-possible-for-adults-progress-report/
http://www.orthodontic-outrage.com/extractions.html
http://deepblue.lib.umich.edu/bitstream/handle/2027.42/27665
/0000047.pdf?sequence=1
http://ormco.com/products/damon-system/case-studies.php
http://www.bos.org.uk/public-patients-home/orthodontics-foradults/adult-faq/will-i-need-to-have-teeth-extracted
http://ejo.oxfordjournals.org/content/24/4/407.full.pdf
http://www.facefocused.com/ReOpen.html
http://en.wikipedia.org/wiki/Serial_extraction
http://www.luvmysmile.com/orthodontic-dilemma-toothextraction-for-braces/
http://www.abariorthodontics.com/nonextraction.html
http://occlusionconnections.com/Orthodontics/blog/orthodonti
c-bicuspid-extraction-correlation-to-tmd-risk-factors/
http://www.bkped.com/dental-treatment/tooth-extractions.aspx
http://www.smilepage.com/controversies/orthodontic_extractio
ns.htm
http://www.arnettgunson.com/education-materials/orthodonticpreparation
http://www.wassonortho.com/pdfs/extractionorthogram.pdf
http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=354
6&Type=PAID&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=278&
isPDF=YES
http://www.aapd.org/assets/1/25/kuthy-16-03.pdf
http://www.stratfordorthodontics.ca/Treatment/Extractions.as
px
http://www.hindawi.com/journals/crid/2014/657657/
http://ask.metafilter.com/236492/Should-I-get-teethextracted-or-do-I-keep-them
http://www.ejco-journal.com/orthodontic-treatment-mechanicsafter-the-extraction-of-second-premolars/
http://www.mynapervillebraces.com/orthodontic-extractions/
http://www.wemakesmilesva.com/dental-procedures/simpleextractions.html
http://ferntreeorthodontics.com.au/default.php?tc=are_braces
http://www.e-aat.com/article/S1875-4597%2814%29000320/abstract?cc=y
http://link.springer.com/article/10.1186%2Fs40510-014-0051-z
https://answers.yahoo.com/question/index?qid=20111209174642A
AewhhV
http://www.fasttraxortho.com/when_to_begin_treatment.htm
96
Table C.1: Continued
Search
Ranking Website Address
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
https://www.scripps.edu/hr/benefits/forms/Dental_Understandi
ng_Orthodontic_Benefits.pdf
http://www.nosebreathe.com/orthodontics.html
http://www.medicinenet.com/script/main/art.asp?articlekey=90
272&page=2
http://www.jcpsp.pk/archive/2010/Jul2010/08.pdf
http://drscheuerman.com/Orthoextraction.htm
http://www.orthobybradford.com/Treatment/Are-ExtractionsNecessary.aspx
http://www.dental-health.com/faq_extraction_orthodontics.html
http://www.tjspahldds.com/extracting_teeth.htm
http://www.scopemed.org/?mno=153666
http://orthoams.com/Orthodontics_Art_Meets_Science/Publicati
ons_files/446s.pdf
http://www.e-aat.com/article/S1875-4597%2814%29000320/abstract
http://www.lakewoodfamilydental.com/general-dentistry/toothextractions.php#.VDCEhhDlsYI
http://www.city-data.com/forum/dental-health/2160356-whywould-orthodontist-do-extractions-after.html
www.rcdso.org/save.aspx?id=9b8c72ff-67b6-4683-849c..
http://www.advanceddentalartsnw.com/blog/a-word-about-nonextraction-orthodontics/
http://www.uhbristol.nhs.uk/for-clinicians/our-clinicalservices/orthodontics
http://www.ajodo.org/article/S0889-5406%2811%29005737/abstract
http://www.monadnockorthodontics.com/patient-education/areextractions-necessary/
http://www.columbia.edu/itc/hs/dental/D5300/ADVERSE%20EFFECT
%20OF%20ORTHODONTIC%20TREATMENT_BW.pdf
http://curetoothdecay.com/blog/assembly-line-orthodonticscan-damage-faces/
http://www.newsmileshappen.com/extractions.html
http://www.bedontortho.com/extractions/
http://www.ozident.com/orthodontic-extractions/
http://www.austinorthodonticarts.com/treatments.php
http://www.mykidsmile.com/extractions
http://orthotropics.org/Discover_Orthotropics/indexf.php?ACT
=To_extract_or_not
http://medind.nic.in/cab/t13/i2/cabt13i2p206.pdf
http://www.kstreetdental.com/extractions.php
http://orthofree.com/fr/default.asp?contentID=2282
http://puresmile.com/patient-education/orthodonticterms/extractions/
http://www.kingssmiles.com/2014/02/avoid-teeth-extractionorthodontic-expanders/
97
Table C.1: Continued
Search
Ranking Website Address
89
90
91
92
93
94
95
96
97
98
99
100
http://www.montanaroorthodontics.com/assets/uploads/forms/Th
eHollywoodSmile.pdf
http://orthodontics.nl/documents/StalpersAmJOrthodDentofacOr
thop2007132316323.pdf
http://www.lincolnwaydentalcenter.com/orthodontics.html
http://www.baltimorecosmeticimplantdentist.com/no_extraction
_orthodontics.html
http://etd.uthsc.edu/WORLD-ACCESS/Shannon/2011-039Shannon.pdf
http://jeffersondental.com/functional-orthodontics.html
http://dallasaffordabledentistry.com/patienteducation/treatments/tooth-extractions/
austinpublishinggroup.org/dentalapplications/download.php?file..
www.banglajol.info/bd/index.php/BJODFO/article/download/.../
11479
http://www.thedentalelf.net/2014/09/15/orthodontictreatment-for-crowding-review-found-similar-results-withearly-and-late-extractions/
http://www.okeeffeorthodontics.com/treatment-requiringextraction-of-teeth.html
http://www.lvoralsurgery.com/#!orthodontic-extractions/c17ps
Table C.2: Unfiltered Search Results for the Search Term
“braces extractions”
Search
Ranking
1
2
3
4
5
6
7
8
9
10
11
Website Address
http://www.archwired.com/Extractions_for_Braces.htm
http://www.gregjorgensen.com/blog/2012/05/will-having-teethremoved-ruin-my-face/
http://doctorbase.com/ask-a-doctor/10960/Will-I-get-mybraces-put-on-the-same-day-I-get-my-teeth-pulled
http://www.thetoothmover.com/crowding-extractions/
http://www.realself.com/question/lips-after-extraction
http://www.youtube.com/watch?v=zqX51OeXXlc
http://www.youtube.com/watch?v=mnjCCjWxldg
http://www.city-data.com/forum/dental-health/2160356-whywould-orthodontist-do-extractions-after.html
http://www.bracesguide.com/contoversial/controversial1.html
http://www.alstonortho.com/Patient-Info/Before-andAfter.aspx
https://answers.yahoo.com/question/index?qid=20130118145341A
AwD7uM
98
Table C.2: Continued
Search
Ranking Website Address
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
http://www.dental--Health.com/faq_extraction_orthodontics
.html
http://ask.metafilter.com/236492/Should-I-get-teethextracted-or-do-I-keep-them
http://www.facefocused.com/ReOpen.html
http://www.luvmysmile.com/orthodontic-dilemma-toothextraction-for-braces/
http://www.public.iastate.edu/~lora/braces_decision.html
http://jjb.yuku.com/topic/672841
http://www.christensenorthodontics.com/damon-braces.html
http://www.answers.com/Q/Can_you_have_extractions_while_wear
ing_braces
http://www.northsydneyorthodontics.com.au/extractionorthodon
tics.htm
http://www.fantasticsmiles.com/beforeafter.asp
http://www.wexfordorthodontics.ie/treatment-results/
http://www.mysmilenshine.com/surgical.php
http://www.nosebreathe.com/orthodontics.html
http://www.blackrockorthodontics.ie/before-after-images/
http://www.imamother.com/forum/viewtopic.php?t=217751
https://www.healthtap.com/topics/braces-with-extractionsbefore-and-after
http://healthquestions.medhelp.org/teeth-extraction-withbraces
http://www.drlouderback.com/post-treatment-instructionsextractions.php
http://www.forrestortho.com/before-and-after
http://www.sr-orthodontics.com/before-and-after
http://www.fasttraxortho.com/when_to_begin_treatment.htm
http://www.estherxie.com/2014/06/braces-toothextractions.html
http://www.jamesgilsdorfdds.com/library/82/Extractions.html
http://markhamortho.blogspot.com/2011/02/extraction-withbraces-vs-non.html
http://www.centuryorthodontics.com/extractions...why.doc
http://www.princetonorthodontics.net/treatment/before-ampafter.aspx
http://www.netmums.com/coffeehouse/tweens-teens-581/teens61/592756-my-teen-needs-teeth-extracted-braces-how-muchdoes-hurt-worth-all.html
http://www.evancarmichael.com/Public-Relations/7235/How-toAvoid-Braces-and-Unnecessary-Extractions.html
https://www.facebook.com/media/set/?set=a.829773510372329.10
73741832.703299106353104&type=3
http://dental.udmercy.edu/patient/
https://www.smilecolumbia.com/pre-orthodontic-extractionsis-there-a-better-way/
99
Table C.2: Continued
Search
Ranking Website Address
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
http://claimingpower.com/reverse-extraction-orthodontics-isit-possible-for-adults-progress-report/
http://www.biomedox.com/media/teeth-extractions-for-bracesinvisalignorthodontics-treatments_1381df22c.html
http://www.bloomingtonbraces.com/library/82/Extractions.html
http://barbieriortho.com/treatment/extractions/
http://www.yourdentistryguide.com/tooth-extraction/
http://www.tjspahldds.com/extracting_teeth.htm
http://mrsbraceface.wordpress.com/
http://www.nobraces.com.au/no-extractions.php
http://www.bracesinfo.com/question/developing-tmj-anddished-in-profile-due-to-extractions-and-braces.html
http://sanantonioortho.com/extractions-order-braces/
http://www.what-a-smile.com/Treatment/Are-ExtractionsNecessary-.aspx
http://www.spielberg-ortho.com/officeinfo/blog/entryid/9/will-i-need-to-have-teeth-extractedbefore-getting-braces.aspx
http://curetoothdecay.com/blog/assembly-line-orthodonticscan-damage-faces/
http://www.smilesolutions.com.au/orthodontics/braces-forchildren-and-teenagers
http://forums.soompi.com/discussion/340906/braces-and-teethextraction/p2
http://www.dentalphobia.co.uk/answers/do-i-need-teeth-to-beextracted-before-braces-treatment/
http://www.medicinenet.com/script/main/art.asp?articlekey=90
272&page=2
http://drgeorgedds.com/braces-faqs.htm
http://www.petalumabraces.com/type-of-orthoproblems/extractions/
http://www.alvarezortho.com/common-treatments
http://www.lakeconroedental.com/extractions.php
http://www.dentalguide.co.uk/patient_guide/damon-system.html
http://www.bos.org.uk/public-patients-home/orthodontics-foradults/adult-faq/will-i-need-to-have-teeth-extracted
http://www.sabbaghoralsurgery.com/wisdom-teeth-removalextractions
http://www.orthopractice.com/smilegallery/
http://www.crossboworthodontic.com/caapp.htm
http://www.orthodonticsofcambridge.com/PatientInfo/Beforeamp
After.aspx
http://www.bracesreview.com/forums/entries/2577-Emergency!Do-i-really-need-extractions-for-braces
http://myvoorheesnjdentist.com/braces
http://www.healthboards.com/boards/dental-health/983910need-extractions-braces-need-advice.html
100
Table C.2: Continued
Search
Ranking Website Address
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
http://community.babycenter.com/post/a39267532/braces_and_ex
tractions
http://www.powaybraces.com/specialties/damon-braces/
http://www.dailymotion.com/video/x1qyew3_extractions-forbraces-nacogdoches-tx-281-816-4707_news
http://www.dewittorthodontics.com/damon/damon-braces.html
http://www.veryniceteeth.com/index.php/patienteducation/extraction-vs-non-extraction
http://community.cookinglight.com/archive/index.php/t118124.html
http://www.bedontortho.com/extractions/
http://www.hertsorthodontics.com/treatment/before-afterbraces.html
http://www.ndcs.com.sg/ForPatientsAndVisitors/ConditionsAndT
reatments/Glossary/Pages/OrthodonticsPreparingforBraces.aspx
http://www.advanceddentalartsnw.com/blog/a-word-about-nonextraction-orthodontics/
http://www.newmansortho.com/Fun-Stuff/Blog/EntryId/20/Areextractions-necessary-in-order-to-get-braces.aspx
http://www.theparkdentalclinic.co.uk/cosmetic-dentistderby/category/orthodontics/non-extraction-brace-treatment/
http://www.smileswithoutbraces.com.au/teeth-straghteningorthodontist.html
http://www.manhattanbridgeortho.com/orthodontic-treatmentplan-really-need-extract-teeth/
http://ashscrapyard.wordpress.com/2013/01/05/extractionshurt-braces-hurt-everything-hurts/
http://www.scrippsortho.com/faq/
http://www.mothering.com/forum/308-dental/966121-crowdedteeth-tooth-extraction-really-necessary.html
http://orthodontists.co.nz/patient-info/before-andafter.aspx
http://www.checkdent.com/en/thread/braces-or-extraction-fortwo-front-teeth-1339.html
http://www.mumsnet.com/Talk/general_health/a1468163-How-tohelp-child-cope-with-tooth-extractions-braces
http://www.brushcountrydental.com/2013/01/06/areextractions-necessary-in-order-to-get-braces/
http://www.oasisdentalmilton.com/braces-non-extraction/nonextraction-orthodontic-bone-orthopedic-developement/
http://www.massresources.org/masshealth-dental.html
http://chfs.ky.gov/dms/dental.htm
http://www.pacerdentalpc.com/Services
http://www.drcoetzeebraces.co.za/braces-faqs/
http://www.dentalfearcentral.org/forum/showthread.php?23227Does-tooth-extraction-hurt
http://www.deardoctor.com/inside-the-magazine/issue19/tooth-removal-for-orthodontic-reasons/
101
Table C.3: Unfiltered Search Results for the Search Term
“braces extractions good or bad”
Search
Rankings Website Address
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
http://www.what-a-smile.com/Treatment/Are-ExtractionsNecessary-.aspx
http://ask.metafilter.com/236492/Should-I-get-teethextracted-or-do-I-keep-them
http://www.centuryorthodontics.com/extractions...why.doc
https://answers.yahoo.com/question/index?qid=20100107061330
AAxBCi6
http://www.realself.com/question/lips-after-extraction
http://www.realself.com/question/correct-bad-orthodontics
http://www.gregjorgensen.com/blog/2012/05/will-havingteeth-removed-ruin-my-face/
http://www.gregjorgensen.com/blog/2012/04/why-do-i-needteeth-removed-for-my-braces/
http://www.archwired.com/Extractions_for_Braces.htm
http://www.fasttraxortho.com/when_to_begin_treatment.htm
http://claimingpower.com/reverse-extraction-orthodonticsis-it-possible-for-adults-progress-report/
http://www.yourdentistryguide.com/tooth-extraction/
http://curetoothdecay.com/blog/assembly-line-orthodonticscan-damage-faces/
http://www.youtube.com/watch?v=zqX51OeXXlc
http://www.dental-health.com/faq_extraction_orthodontics.html
http://www.sanilacfamilydentistry.com/
http://www.facefocused.com/ReOpen.html
http://community.cookinglight.com/archive/index.php/t118124.html
http://worldental.org/oral-hygiene/tooth-extraction-care/
http://www.animatedteeth.com/tooth_extractions/t2_teeth_extractions.htm
http://www.webmd.boots.com/oral-health/guide/toothextraction
http://www.thehealthyhomeeconomist.com/skip-that-surgerymost-wisdom-tooth-extractions-unnecessary/
http://cyberdentist.blogspot.com/2005/09/when-is-best-timeto-start-braces.html
http://www.healingteethnaturally.com/orthodontic-treatmentrisks.html
http://www.identalhub.com/article_do%27s-and-don%27tsafter-tooth-extraction-153.aspx
http://www.dentalfearcentral.org/forum/showthread.php?23227
-Does-tooth-extraction-hurt
http://allcaredentalclinic.com/tooth-extraction/
http://www.consumeraffairs.com/dentists/dds_western_dental.
html
http://forums.soompi.com/discussion/151457/is-it-better-toget-braces-before-or-after-your-wisdom-teeth-appear
102
Table C.3: Continued
Search
Ranking Website Address
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
http://www.oralhealthgroup.com/news/orthodontics-more-thanjust-pretty-smiles/1000145697/?&er=NA
http://www.netmums.com/coffeehouse/tweens-teens-581/teens61/592756-my-teen-needs-teeth-extracted-braces-how-muchdoes-hurt-worth-all.html
http://www.laserfillingsnow.com/braces-faqs.html
http://www.orthodontisteenligne.com/en/faq-en/faqsfrequently-asked-questions-in-orthodontics/
http://www.dentalassociates.com/dental-education/tobaccoand-oral-health/
http://www.cosmeticdentistryguide.co.uk/lingual-braces.html
http://www.bracesquestions.com/static/braces-intro/10myths-about-braces/
http://youngwomenshealth.org/2012/08/14/braces/
http://www.healthgrades.com/procedures/dental-braces
http://www.livestrong.com/article/180780-dental-extractionside-effects/
http://www.foothillsdentalcentre.com/orthodontics.html
http://www.home-remedies-for-you.com/blog/pain-relieftooth-extraction.html
http://www.fantasticsmiles.com/beforeafter.asp
http://swapna123.hubpages.com/hub/visit-to-a-dentist
http://www.bracesreview.com/forums/entries/2577-Emergency!Do-i-really-need-extractions-for-braces
http://parents.berkeley.edu/advice/health/extraction.html
http://www.smileswithoutbraces.com.au/
http://www.planetbraces.com/common-orthodonticsquestions.php
http://bracesindelaware.com/page-just-teenagers
http://dentalcarematters.com/best-mouthwash/
http://www.yelp.com/biz/new-york-university-college-ofdentistry-new-york
http://www.bayareasmilesfl.com/faqs
http://www.sanantoniotxortho.com/patient-resources/faq/
http://jeffersondental.com/functional-orthodontics.html
http://orthocj.com/2009/04/extraction-choice-in-the-era-ofevidence-based-orthodontics/
http://doctorspiller.com/Extractions/extractions.htm
http://www.poserortho.com/common-questions.php
http://www.vivawoman.net/2013/09/removing-wisdom-toothchanged-face-shape/
http://www.wowortho.com/questions-and-answers.php
http://mrsbraceface.wordpress.com/
www.rcdso.org/save.aspx?id=9b8c72ff-67b6-4683-849c...
http://www.junction-orthodontics.com/hot-topics/earlytreatment-does-my-child-need-it
103
Table C.3: Continued
Search
Ranking Website Address
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
http://www.theschulhofcenternj.com/adult-ortho-blog/DoBraces-Change-Facial-Structure-For-Adults
http://www.healthboards.com/boards/dental-health/34806tooth-abcess-extraction-root-canal-before-braces.html
http://www.virgultiorthodontics.com/best.shtml
http://doctor.ndtv.com/faq/ndtv/fid/2608/Does_extraction_of
_teeth_for_braces_or_clips_have_any_side_effects.html
http://jasers.com/?p=98
http://www.smilesolution.co.uk/faqs
http://www.forrestortho.com/for-all-ages
http://www.city-data.com/forum/dental-health/417463pulling-teeth-braces-3.html
http://www.felicianeo.com/braces-101-5/
http://jawpain-tmjtreatment.com/
http://www.webmd.com/oral-health/guide/care-of-bracesretainers
http://www.urbanmamas.com/urbanmamas/2011/08/braces-sooneror-later.html
http://www.damagedfaces.com/index.php?option=com_content&vi
ew=section&layout=blog&id=5&Itemid=54
http://www.southlandsmiles.com/services.html
http://dentallecnotes.blogspot.com/2011/07/note-onextractions-in-orthodontics.html
http://boards.straightdope.com/sdmb/showthread.php?t=697581
http://www.1800dentist.com/low-income-dental-care/
http://kidshealth.org/teen/diseases_conditions/mouth/braces
_rachel.html
http://www.brightnow.com/ortho/faqs
http://www.starlingorthodontics.com/faqs
http://www.foxdentistry4kids.com/orthodontics/treatment.htm
l
http://www.surbeckortho.com/treatment-info/earlytreatment.aspx
http://www.pediatricdentalcare.org/sedation
http://www.wheelingit.us/2013/01/16/getting-dental-work-inmexico-part-i-clarifying-myths-facts/
http://www.westonaprice.org/holistic-healthcare/is-itmental-or-is-it-dental/
http://loveinyourarms.blogspot.com/2012/09/all-aboutbraces.html
http://boards.weddingbee.com/topic/i-have-to-have-a-toothextracted-tomorrow-is-it-going-to-totally-suck/
http://www.studiodentaire.com/questions/en/which-is-betterretainers-or-braces.php
http://thenobraceplace.com/
http://claritybracesat38.wordpress.com/
http://www.excellencedental.net/faqs
104
Table C.3: Continued
Search
Ranking Website Address
93
94
95
96
97
98
99
100
http://blogs.msdn.com/b/cwilso/archive/2006/08/23/715640.as
px
http://www.cosmeticdentistofny.com/dental_services5.html
http://www.dentalguide.co.uk/patient_guide/lingualbraces.html
http://www.mylifemysmile.org/glossary
http://www.demandforce.com/b/comfort-dental-care-andorthodontics
http://www.magnusonortho.com/home/all-abouttreatment/before-and-after/
http://www.justjaslin.com/2011/07/braces-ep-234-polishingdecay.html
http://www.ejco-journal.com/wpcontent/uploads/2013/11/Bennett.pdf
Table C.4: Unfiltered Search Results for the Search Term
“orthodontics without extractions”
Search
Ranking
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Website Address
http://www.gregjorgensen.com/blog/2012/05/are-therealternatives-to-having-teeth-removed-for-braces/
http://www.advanceddentalartsnw.com/blog/a-word-about-nonextraction-orthodontics/
http://www.nosebreathe.com/orthodontics.html
http://onlinelibrary.wiley.com/doi/10.1111/j.18347819.2005.tb00353.x/pdf
http://ask.metafilter.com/236492/Should-I-get-teethextracted-or-do-I-keep-them
http://www.centuryorthodontics.com/extractions...why.doc
http://www.thetoothmover.com/crowding/
http://ferntreeorthodontics.com.au/default.php?tc=are_braces
http://www.bos.org.uk/public-patients-home/orthodontics-foradults/adult-faq/will-i-need-to-have-teeth-extracted
http://www.northsydneyorthodontics.com.au/extractionorthodon
tics.htm
https://www.smilecolumbia.com/pre-orthodontic-extractionsis-there-a-better-way/
http://www.alforthodontics.com/Dr_McDermott%20article.pdf
http://www.fantasticsmiles.com/beforeafter.asp
http://www.veryniceteeth.com/index.php/patienteducation/extraction-vs-non-extraction
http://www.nature.com/bdj/journal/v196/n4/full/4810979a.html
105
Table C.4: Continued
Search
Ranking Website Address
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
http://www.realself.com/question/correct-buck-teethextraction-damon
http://www.archwired.com/Extractions_for_Braces.htm
http://www.youtube.com/watch?v=zqX51OeXXlc
http://www.inner-smiles.com/
http://www.ajodo.org/article/S0889-5406%2895%2970079X/abstract?cc=y
http://www.scielo.br/scielo.php?pid=S217694512010000300017&script=sci_arttext&tlng=en
http://markhamortho.blogspot.com/2011/02/extraction-withbraces-vs-non.html
https://sg.answers.yahoo.com/question/index?qid=201007200747
35AAzqu27
http://www.ncbi.nlm.nih.gov/pubmed/7625391
http://www.ajodo.org/article/S0889-5406%2802%29000367/abstract
http://www.24-7pressrelease.com/press-release/think-twicebefore-extracting-teeth-for-ortho-15221.php
http://ejo.oxfordjournals.org/content/1/3/201.abstract
http://claimingpower.com/reverse-extraction-orthodontics-isit-possible-for-adults-progress-report/
http://www.researchgate.net/publication/11239034_Changes_in_
soft_tissue_profile_after_orthodontic_treatment_with_and_wit
hout_extractions
http://www.orthodontic-outrage.com/pressrelease2.html
http://orthocj.com/2009/04/extraction-choice-in-the-era-ofevidence-based-orthodontics/
http://www.dentalpedia.ca/treatments/extractions/
http://www.abariorthodontics.com/nonextraction.html
http://unitydental.com.au/wpcms/is-it-possible-to-doorthodontics-without-extractions/
http://www.bracesguide.com/contoversial/controversial1.html
http://www.orthodontisteenligne.com/en/faq-en/faqsfrequently-asked-questions-in-orthodontics/
http://orthodontists.co.nz/patient-info/before-andafter.aspx
http://www.blin-ayusawa.com/en/kyousei/bassi.html
http://sixtyminutes.ninemsn.com.au/article/259072/straighttalk
http://ormco.com/products/damon-system/case-studies.php
http://www.sr-orthodontics.com/before-and-after
http://www.growthorthodontics.com/#!about/ccys
http://www.hamiltonorthodontics.co.nz/cp_moderatecrowding.ht
ml
http://www.clinicarojaspardini.com/index.php?option=com_cont
ent&view=article&id=28&Itemid=131
http://www.jeanfrancoisernoult.com/bases/slot_cas_pdf/23/fichier.pdf
106
Table C.4: Continued
Search
Ranking Website Address
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
http://www.perrinorthodontics.com/treatment_gallery.php
http://www.rinchuseorthodontics.com/#!extractiontreatment/c3mz
http://orthotropics.org/Discover_Orthotropics/indexf.php?ACT
=To_extract_or_not
http://www.vardyorthodontics.com/children-and-teenorthodontics.php
http://www.gcdental.com.au/non_extraction_orthodontics.htm
http://www.dental-tribune.com/articles/specialities/
orthodontics/9617_how_to_avoid_extractions_when_treating_
malocclusions_using_mrcs_bent_wire_system_bws_and_trainer_sy
stem_for_arch_development.html
http://www.harwellortho.com/Treatment/Damon.aspx
http://www.orthodonticswithoutbraces.com/#!faq/c121r
http://connection.ebscohost.com/c/articles/59904320/orthodon
tic-space-closure-after-first-molar-extraction-withoutskeletal-anchorage
http://www.facefocused.com/ReOpen.html
http://batteryparkorthodontist.com/battery_park_damon.htm
http://www.mynapervillebraces.com/orthodontic-extractions/
http://www.dental-health.com/faq_extraction_orthodontics.html
http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=354
6&Type=PAID&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=278&
isPDF=YES
http://www.dewittorthodontics.com/damon/damon-braces.html
http://www.deardoctor.com/inside-the-magazine/issue19/tooth-removal-for-orthodontic-reasons/
http://www.spielberg-ortho.com/officeinfo/blog/entryid/9/will-i-need-to-have-teeth-extractedbefore-getting-braces.aspx
http://www.scopemed.org/?mno=153666
http://www.wahroongadental.com.au/non-extractionorthodontics/
http://www.luvmysmile.com/orthodontic-dilemma-toothextraction-for-braces/
http://www.orthotechnology.com/product_literature/pdfs/MGBM_
system.pdf
http://www.progressinorthodontics.com/content/pdf/s40510014-0051-z.pdf
http://www.academia.edu/1809037/Nonextraction_Orthodontic_Treatment_in_Management_of_Moderately
_Crowded_Class_II_Division_2_Malocclusion_A_Case_Report
http://stevensonhanisorthodontics.com/right-age.php
http://www.drajsuri.com/testimonials/crowding-withoutextraction/
http://www.goingsorthodontics.com/Practice-Blog.aspx
http://www.rivervieworthodontics.com/treatment/treatmentwith-extractions.aspx
107
Table C.4: Continued
Search
Ranking Website Address
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
http://www.bedontortho.com/extractions/
http://inortho.ca/2011/11/extractions-or-no-extractions/
http://www.jcpsp.pk/archive/2010/Jul2010/08.pdf
http://www.showmesmiles.com/Patient-Info/Why-Age-7.aspx
http://www.jco-online.com/archive/articleview.aspx?year=2007&month=01&articlenum=33
http://orthotropics.com/
http://www.bayorthodontics.co.nz/faq/
http://endoexperience.com/documents/Nowzari_Accelerated_Orth
oDOWNSIZED.pdf
http://www.eastfieldpedoortho.com/home/eastfield_dentistryorthodontics.php
http://www.smileswithoutbraces.com.au/teeth-straghteningorthodontist.html
http://www.aapd.org/assets/1/25/kuthy-16-03.pdf
http://www.arnettgunson.com/education-materials/orthodonticpreparation
http://www.prigofforthodontics.com/non-extractiontreatment.aspx
http://www.gaorthocare.com/gaorthocare_005.htm
http://www.slideshare.net/dr_abi/serial-extraction-29847441
http://digitallibrary.usc.edu/cdm/ref/collection/p15799coll1
27/id/330600
http://www.philadelphiaorthodontists.com/before-aftersmiles.html
http://www.iwamotoshika.com/e-c.html
http://orthofree.com/fr/default.asp?contentID=2282
http://www.darmitzelortho.com/dr.-dsblog/entryid/5/extractions.aspx
http://www.medicinaoral.com/pubmed/medoralv15_i5_p760.pdf
http://www.harringtonorthodontics.com/class-iii-nonextraction
http://www.realsmile.com/services/orthodontic-treatment/
http://www.stunningsmiles.co.nz/wawcs0138968/idDetails=181/E
xtractions%20in%20orthodontics
http://www.schratzorthodontics.com/faq.html?hgm=1_1
http://www.kiheiorthodonticsmaui.com/Common-Problems/WhyAge-7.aspx
http://tools.televoxsites.com/damon/DamonPhotoAlbum.swf
http://www.chapelroad.co.uk/cases-kent-orthodontist/casesbexleyheath-orthodontist.html
108
Table C.5: Unfiltered Search Results for the Search Term
“braces without extractions”
Search
Ranking Website Address
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
http://www.gregjorgensen.com/blog/2012/05/are-therealternatives-to-having-teeth-removed-for-braces/
http://ask.metafilter.com/236492/Should-I-get-teethextracted-or-do-I-keep-them
http://www.advanceddentalartsnw.com/blog/a-word-about-nonextraction-orthodontics/
http://www.bracesguide.com/contoversial/controversial1.html
http://www.sr-orthodontics.com/before-and-after
https://www.zocdoc.com/answers/14358/can-i-get-braceswithout-needing-to-have-any-teeth-pulled
http://www.nosebreathe.com/orthodontics.html
http://www.bos.org.uk/OneStopCMS/Core/TemplateHandler.aspx?N
RMODE=Published&NRNODEGUID={311DABE7-A9A2-41F8-8208A952C78B0B04}&NRORIGINALURL=%2fpublic-patientshome%2forthodontics-for-adults%2fadult-faq%2fwill-i-need-tohave-teeth-extracted&NRCACHEHINT=NoModifyGuest
http://www.thetoothmover.com/crowding/
http://www.realself.com/question/correct-buck-teethextraction-damon
http://www.realself.com/question/extract-teeth-wear-bracesoverbite
http://www.realself.com/question/fix-mild-crowding-withoutextraction-bicuspids
http://www.northsydneyorthodontics.com.au/extractionorthodon
tics.htm
https://sg.answers.yahoo.com/question/index?qid=201007200747
35AAzqu27
http://www.fantasticsmiles.com/beforeafter.asp
http://www.youtube.com/watch?v=zqX51OeXXlc
http://www.youtube.com/watch?v=LbDgdkhWbWk
http://www.archwired.com/Extractions_for_Braces.htm
http://www.damonbraces.com/choose/teeth-pulled.php
http://ferntreeorthodontics.com.au/default.php?tc=are_braces
http://markhamortho.blogspot.com/2011/02/extraction-withbraces-vs-non.html
http://www.public.iastate.edu/~lora/braces_decision.html
https://www.smilecolumbia.com/pre-orthodontic-extractionsis-there-a-better-way/
http://www.jfdental.com/media/straight-teeth-withoutextraction-braces/
http://www.smileswithoutbraces.com.au/teeth-straghteningorthodontist.html
http://www.smileswithoutbraces.com.au/teeth-straghteningorthodontist.html
http://www.christensenorthodontics.com/damon-braces.html
http://www.dewittorthodontics.com/damon/damon-braces.html
109
Table C.5: Continued
Search
Ranking Website Address
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
http://www.mothering.com/forum/308-dental/966121-crowdedteeth-tooth-extraction-really-necessary.html
http://www.bracesinfo.com/question/braces-withoutextractions.html
http://www.dental-health.com/faq_extraction_orthodontics.html
http://www.spielberg-ortho.com/officeinfo/blog/entryid/9/will-i-need-to-have-teeth-extractedbefore-getting-braces.aspx
http://www.alliedorthodontics.com/damonbraces.php
http://orthodontists.co.nz/patient-info/before-andafter.aspx
http://sixtyminutes.ninemsn.com.au/article/259072/straighttalk
https://www.facebook.com/media/set/?set=a.829773510372329.10
73741832.703299106353104&type=3
http://www.profident.by/page.php?id=93&lang=gb
http://www.orthodontisteenligne.com/en/faq-en/faqsfrequently-asked-questions-in-orthodontics/
http://claimingpower.com/reverse-extraction-orthodontics-isit-possible-for-adults-progress-report/
http://www.luvmysmile.com/orthodontic-dilemma-toothextraction-for-braces/
http://batteryparkorthodontist.com/battery_park_damon.htm
http://www.thonglordentalhospital.com/dentaltreatment/orthodontics/self-ligating-braces
http://www.veryniceteeth.com/index.php/patienteducation/extraction-vs-non-extraction
http://www.nobraces.com.au/nobrace-arch-developmentsystem.php
http://www.yellowpages.com.au/nsw/lindfield/smiles-withoutbraces-14857831-listing.html
http://ormco.com/products/damon-system/case-studies.php
http://www.goodhealthdentistry.com.au/smiles-without-braces
http://www.missioncreekortho.com/before_after.php
http://forums.soompi.com/discussion/340906/braces-and-teethextraction/p3
http://healthquestions.medhelp.org/teeth-extraction-withbraces
http://www.oceanorthodontics.com.au/services/braces-gallerybefore-and-after/
http://www.24-7pressrelease.com/press-release/think-twicebefore-extracting-teeth-for-ortho-15221.php
http://inortho.ca/2011/11/extractions-or-no-extractions/
http://www.gaorthocare.com/gaorthocare_005.htm
http://www.brbraces.com/types-of-braces/damon-reg.aspx
http://www.milestoneorthodontics.com/treatment/braces
http://asmileworks.org/results/
http://www.tjspahldds.com/extracting_teeth.htm
110
Table C.5: Continued
Search
Ranking Website Address
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
http://www.hamiltonorthodontics.co.nz/cp_moderatecrowding.ht
ml
http://www.gcdental.com.au/non_extraction_orthodontics.htm
http://whatisorthodontics.com/braces-without-extraction.html
http://www.smilesolutions.com.au/orthodontics/braces-forchildren-and-teenagers
http://www.mynapervillebraces.com/orthodontic-extractions/
http://bracesbybrigance.com/portfolio/class-ii-treatedwithout-extractions-2/
http://www.douglasknightorthodontics.com/PatientInfo/Before-amp-After.aspx
http://www.fasttraxortho.com/when_to_begin_treatment.htm
http://www.ellevendental.com/orthodontics/damon-braces/
http://www.nvyoursmile.com/About_Braces/DamonSystem
http://www.inner-smiles.com/
http://www.hertsorthodontics.com/treatment/self-ligatingbraces-pros-cons.html
http://raisingchildren.net.au/forum/Topic27252-22-1.aspx
http://www.thehealthyhomeeconomist.com/skip-that-surgerymost-wisdom-tooth-extractions-unnecessary/
http://www.pearlywhitesnj.com/orthodontics/braces-faq.shtml
http://www.aeortho.com/adults
http://www.yourdentistryguide.com/tooth-extraction/
http://www.orthodonticsbycrutchfield.com/what-we-do/damonsystem/
http://www.welmerinkorthodontics.com/treatment/types-ofbraces.aspx
http://www.drkurtortho.com/before-and-after.php
http://www.theschulhofcenternj.com/adult-ortho-blog/DoBraces-Change-Facial-Structure-For-Adults
http://www.chelseadental.co.uk/cosmetic-dentistry/damonbraces/
http://www.identalhub.com/article_getting-teeth-pulled-outfor-braces-treatment-876.aspx
http://www.soniortho.com/Treatment/Damon-Braces.aspx
http://orthodonticarts.net/treatments/damon-braces/
http://curetoothdecay.com/blog/assembly-line-orthodonticscan-damage-faces/
http://www.philadelphiaorthodontists.com/before-aftersmiles.html
http://tools.televoxsites.com/damon/DamonPhotoAlbum.swf
http://www.socialanxietysupport.com/forum/f26/gettingbraces-167368/
http://jeffdavisdental.com/services/
http://www.jkaplanortho.com/treatments/damon-braces/
http://www.mcosmiles.com/before-and-after
111
Table C.5: Continued
Search
Ranking Website Address
91
92
93
94
95
96
97
98
99
100
http://www.medicinenet.com/script/main/art.asp?articlekey=90
272&page=2
http://www.amley-amley.com/damon_system.html
http://www.americanriverorthodontics.com/our-services/damonsystem
http://www.stunningsmiles.co.nz/wawcs0138968/idDetails=181/E
xtractions%20in%20orthodontics
http://www.adelspergerortho.com/damonsystem.pdf
http://dentallecnotes.blogspot.com/2011/07/note-onextractions-in-orthodontics.html
http://www.dentalfearcentral.org/forum/showthread.php?24154they-want-4-premolars-extracted-for-braces
http://www.stanleymasaki.com/
http://www.bracesquestions.com/static/braces-intro/10-mythsabout-braces/
http://www.city-data.com/forum/dental-health/2160356-whywould-orthodontist-do-extractions-after.html
Table C.6: Unfiltered Search Results for the Search Term
“non-extraction orthodontist”
Search
Ranking
1
2
3
4
5
6
7
8
9
10
11
12
13
Website Address
http://www.advanceddentalartsnw.com/blog/a-word-about-nonextraction-orthodontics/
http://www.veryniceteeth.com/index.php/patienteducation/extraction-vs-non-extraction
http://www.manhattanbridgeortho.com/orthodontic-treatmentplan-really-need-extract-teeth/
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3757883/
http://www.comfortsmilesatlanta.net/index.php/dentalservices/non-extraction-and-expansion-orthodontics
http://www.nosebreathe.com/orthodontics.html
http://onlinelibrary.wiley.com/doi/10.1111/j.18347819.2005.tb00353.x/pdf
http://nextortho.com/
http://www.angle.org/doi/full/10.2319/051911-339.1
http://www.abariorthodontics.com/nonextraction.html
http://www.centuryorthodontics.com/extractions...why.doc
http://www.thetoothmover.com/crowding/
http://www.inner-smiles.com/ortho-news-articles/orthodonticextractions
112
Table C.6: Continued
Search
Ranking Website Address
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
http://www.inner-smiles.com/orthodontic-services-coloradosprings/orthodontic-extractions
http://www.bracesguide.com/contoversial/controversial1.html
http://www.youtube.com/watch?v=ZVSWdxha1rw
http://www.youtube.com/watch?v=pb7R86dAyls
http://www.orthotechnology.com/product_literature/pdfs/MGBM_
system.pdf
http://www.milestoneorthodontics.com/awards?id=25
https://answers.yahoo.com/question/index?qid=20101219083717A
ATagsH
http://www.progressinorthodontics.com/content/14/1/47
http://ejo.oxfordjournals.org/content/20/3/225.full.pdf
http://www.sciencedirect.com/science/article/pii/S0889540604
006936
http://www.academia.edu/1809037/Nonextraction_Orthodontic_Treatment_in_Management_of_Moderately
_Crowded_Class_II_Division_2_Malocclusion_A_Case_Report
http://www.scirp.org/journal/PaperInformation.aspx?PaperID=2
2663
http://www.baltimorecosmeticimplantdentist.com/no_extraction
_orthodontics.html
http://www.prigofforthodontics.com/non-extractiontreatment.aspx
http://omicsonline.org/external-apical-root-resorptionafter-six-and-12-months-of-non-extraction-orthodontictreatment-2161-1122.1000102.php?aid=1760
http://www.harringtonorthodontics.com/class-iii-nonextraction
http://wertzortho.com/tag/non-extraction-orthodontics/
http://www.researchgate.net/publication/262016830_Comparison
_of_orthodontic_treatment_outcomes_in_nonextraction_2_maxill
ary_premolar_extraction_and_4_premolar_extraction_protocols_
with_the_American_Board_of_Orthodontics_objective_grading_sy
stem
https://www.novapublishers.com/catalog/product_info.php?prod
ucts_id=42094
http://www.drmooredds.com/12.html
http://ecommons.aku.edu/cgi/viewcontent.cgi?article=1016&con
text=pakistan_fhs_mc_surg_dent_oral_maxillofac
http://www.hindawi.com/journals/crid/2012/694527/
http://orthocj.com/2012/07/orthodontic-extraction-whenwhere-what/
http://www.drjmayortho.com/functional-appliances.php
http://www.montanaroorthodontics.com/assets/uploads/forms/Th
eHollywoodSmile.pdf
http://www.orthopracticeus.com/home/columns/456-biodigitalorthodontics-management-of-patients-with-class-2malocclusion-non-extraction-ii-part-9
http://www.fasttraxortho.com/when_to_begin_treatment.htm
113
Table C.6: Continued
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Ranking Website Address
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
http://www.cignaorthodontics.com/hub_sites/cignasalvatore/www/assets/uploads/files/CignaNONEXTRACT.pdf
http://www.mcdowellorthodontics.com/treatment-info/beforeand-after?0option=com_content&task=view&id=128
http://tmjcalifornia.com/non-extraction-orthodontics/
http://www.wexfordorthodontics.ie/non-extraction-treatment/
http://www.surgicalrestorative.com/articles/2014/01/toextract-or-not-in-todays-orthodontics-why-are-we-extractingpremolars.html
http://www.slu.edu/Documents/cade/thesis/Gentry_Thesis.pdf
http://occlusionconnections.com/Orthodontics/blog/beyondthe-extraction-vs-non-extraction-tooth-debate-optimalfunction-or-physiologic-impairment/
http://markhamortho.blogspot.com/2011/02/extraction-withbraces-vs-non.html
http://www.scopemed.org/?mno=153666
http://www.dagostinotmj.com/content.aspx?content_id=23
http://www.ajodo.org/article/S0889-5406%2814%29000894/abstract
http://www.jaypeejournals.com/eJournals/ShowText.aspx?ID=311
0&Type=FREE&TYP=TOP&IN=_eJournals/images/JPLOGO.gif&IID=239&
isPDF=YES
http://www.orthouniversity.com/when-to-extract/
http://ormco.com/products/damon-system/case-studies.php
http://www.amazon.com/Oropharyngeal-airway-followingorthodontic-treatment/dp/1249895200
http://www.lifetimedental.com.au/services/orthodontics/
http://www.dentaltown.com/hygienetown/Events.aspx?action=DET
AILS&eid=5563
http://drsjackburrow.com/articles/ToExtractOrNotToExtract.pd
f
http://www.clubbraces.com/blog/2014/03/3-dangers-ofnonextraction-don%25e2%2580%2599t-jump-into-adultorthodontic-treatment
http://www.prohealthsmiles.com/early-orthodontictreatmentnon-extraction-treatment/
http://www.julianperrydentist.co.uk/orthodontics/nonextraction-orthodontics.html
http://www.rinchuseorthodontics.com/#!extractiontreatment/c3mz
http://www.jcpsp.pk/archive/2010/Jul2010/08.pdf
http://www.myorthodontist.co.uk/portfolio-item/nonextraction/
http://www.conlonthompsonorthodontics.com/why-choose.php
http://www.chapelroad.co.uk/orthodontics-kentorthodontist/non-extraction-bexleyheath-orthodontist.html
http://newtonvilleorthodontist.com/new-patients/before-andafter/
114
Table C.6: Continued
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Ranking Website Address
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
http://omicsonline.com/open-access/mandibular-incisorrecrowding-is-it-different-in-extraction-and-nonextractioncases-2247-2452.1000649.pdf
http://www.greenbergortho.com/meet-dr-greenberg.php
http://etd.uthsc.edu/WORLD-ACCESS/Shannon/2011-039Shannon.pdf
http://www.dentaltribune.com/articles/specialities/orthodontics/16296_nonextraction_treatment_of_a_class_ii_case_with_a_missing_mandi
bular_central_incisor_using_a_cadcam_lingual_orthodontic_sys
tem.html
http://www.gcdental.com.au/non_extraction_orthodontics.htm
http://www.georgeortho.com/
http://www.damagedfaces.com/index.php?option=com_content&vie
w=section&layout=blog&id=5&Itemid=54
http://posortho.com/con_interestedstudents.cfm?s=specialty
http://cruikshankorthodontics.com/latest-technology/beforeand-after/
http://www.agourahillsorthodontics.com/before_after_2.htm
http://www.contemporaryorthodontics.com/upper_airway.php
http://gradworks.umi.com/14/91/1491276.html
http://nosebreathe.org/orthodontics.html
http://www.drmediorthodontics.com/faq-adult-treatment.aspx
http://www.slideshare.net/indiandentalacademy/extractioncontraversies-in-orthodontics
http://www.klmortho.com/c_010.html
http://www.dentalpedia.ca/treatments/extractions/
http://www.cesearchengine.com/ce_details.php?ce_id=19473
http://www.realself.com/question/extraction-nonextractionfix-moderate-class-protrusion-w-o-dished-in
http://www.drgraasorthodontist.com/orthodontictreatments/tooth-extraction/
http://www.harrington-ortho.com/extractions.html
http://www.forrestortho.com/before-and-after
http://www.orthotown.com/orthotown/OnlineCE.aspx?action=DETA
ILS&cid=387
http://www.parkerorthodontist.com/newsmiles_228.php
http://drmcqueen4braces.com/faq.html
http://www.robborthodontics.com/patient-education/
http://angolkar4smiles.com/our-gallery/adolescent-treatmentnon-extraction/
http://www.edgarberrejr.com/pages/FAQ/
http://www.nature.com/bdj/journal/v196/n4/full/4810979a.html
http://www.iasj.net/iasj?func=fulltext&aId=9047
http://www.hamiltonorthodontics.co.nz/cp_moderatecrowding.ht
ml
115
Table C.6: Continued
Search
Ranking Website Address
99
100
http://vimeo.com/87298611
http://jeffersondental.com/functional-orthodontics.html
Table C.7: Unfiltered Search Results for the Search Term
“braces”
Search
Ranking Website Address
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
http://en.wikipedia.org/wiki/Dental_braces
http://kidshealth.org/kid/feel_better/things/braces.html
http://www.oralb.com/embraceit/types-of-braces
http://www.webmd.com/oral-health/guide/braces-and-retainers
http://www.youtube.com/watch?v=wh1i-b-TX1g
http://www.invisalign.com/braces-for-adults-and-teens/adults
http://www.invisalign.com/braces-for-adults-and-teens
http://www.braces.org/
http://www.1800dentist.com/dental-braces/
http://www.mouthhealthy.org/en/az-topics/b/braces
http://www.nlm.nih.gov/medlineplus/orthodontia.html
http://bracesofgreece.com/
http://solutions.3m.com/wps/portal/3M/en_US/braces/unitek/
http://solutions.3m.com/wps/portal/3M/en_US/USIncognito/hidden-braces/
http://solutions.3m.com/wps/portal/3M/en_US/braces/unitek/ty
pes/lingual-braces/
http://www.braces.com/index.html
http://www.atlasbrace.com/
http://www.surgerysquad.com/surgeries/braces/
http://www.djoglobal.com/our-brands/donjoy
http://www.medicinenet.com/dental_braces/article.htm
http://en.wiktionary.org/wiki/brace
http://www.leatt.com/
https://github.com/brack3t/django-braces
http://www.urbandictionary.com/define.php?term=braces
http://wildsmilesbraces.com/
http://www.bracesinfo.com/
http://www.bracesinc.com/
116
Table C.7: Continued
Search
Ranking Website Address
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
http://www.ottobockus.com/orthotics/solutionoverview/orthotronic-mobility-system-c-brace/
http://metalmouthmedia.net/
http://www.pythonb.org/
http://paintyoursmile.com/index.php
http://www.aabraces.com/
https://www.facebook.com/thebraces
http://www.mypetsdentist.com/braces-orthodontics.pml
http://www.nhs.uk/Livewell/dentalhealth/Pages/braces.aspx
http://www.health.harvard.edu/healthbeat/HB_web/are-you-tooold-for-braces.htm
clearcorrect.com/what/
http://www.gnu.org/software/bash/manual/html_node/BraceExpansion.html
http://www.ibracesvip.com/
http://www.noevalleysmilesandbraces.com/
http://www.actoralcare.com/act-for-adults/act-braces-caremouthwash/
http://www.bracesbyburris.com/
http://www.walgreens.com/store/c/supports-andbraces/ID=360525-tier2general
http://www.thefreedictionary.com/braces
https://www.dentalhealth.org/tell-meabout/topic/orthodontics/living-with-my-brace
http://www.bracesbybird.com/
http://www.iceclearbraces.com/
http://www.spine-health.com/conditions/scoliosis/typesscoliosis-braces
http://www.yourdentistryguide.com/orthodontics-advantage/
https://django-braces.readthedocs.org/en/v1.4.0/
http://www.amazon.com/b?ie=UTF8&node=3775541
http://www.mylifemysmile.org/glossary
https://my.clevelandclinic.org/health/medicaldevices/hic_Bra
ces_and_Retainers
http://bracesplaces.com/
http://www.ossur.com/injury-solutions/products/knee/customligament-braces/cti-custom
http://mathworld.wolfram.com/Brace.html
http://evs-sports.com/index.php/moto/knee-braces.html
http://www.richiebrace.com/
http://www.brainpop.com/health/personalhealth/braces/preview
.weml
http://www.bracesstables.com/
http://www.bloomberg.com/news/2014-10-04/hong-kong-bracesfor-further-violence-as-tensions-simmer.html
http://www.ctikneebraces.co.uk/
117
Table C.7: Continued
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Ranking Website Address
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
http://oldtoolheaven.com/brace/brace.htm
http://springhillbraces.com/
http://www.archwired.com/
http://www.braceplace.com/
http://comfortdental.com/dental-services/braces/
http://www.walmart.com/ip/ACE-Knee-Brace-with-Dual-SideStabilizers-200290-One-Size-Adjustable/19898440
http://braces-pa.com/
http://www.dentalassociates.com/braces-orthodontics/howbrush-teeth-braces/
http://www.colgate.com/app/CP/US/EN/OC/Information/Articles/
Cosmetic-Dentistry/Orthodontics/OrthodonticCare/article/Protecting-Your-Healthy-Smile-while-WearingBraces.cvsp
http://www.braceplacenaples.com/
http://www.wikihow.com/Choose-the-Color-of-Your-Braces
http://www.animated-teeth.com/dental-braces/b1-lingualbraces.htm
http://www.carolinabraces.com/
http://www.hollywoodbraces.com/
http://www.mcdavidusa.com/sportmed/ankle
http://www.dafo.com/ordering/custom-braces/
http://health.costhelper.com/braces.html
http://bracesbracesbraces.com/locations.php
http://www.breg.com/products/knee-bracing/functionalligament/fusion-knee-brace
http://www.knowyourteeth.com/infobites/abc/article/?abc=c&ii
d=322&aid=1303
http://www.dict.cc/?s=braces
http://www.goldnbraces.com/
http://www.hoytt.com/ears/
http://smileschangelives.org/apply-for-braces
http://www.smilebysanjoseorthodontist.com/
http://www.betterbraces.com/aircast
http://www.mayoclinic.org/tests-procedures/braces/expertanswers/dental-braces/faq-20058192
http://psb.eu/en/
http://www.homedepot.com/b/Building-Materials-BuildersHardware-Corner-Braces/N-5yc1vZc8hr
https://www.shockdoctor.com/ultra-braces-mouthguard
http://pmd.sourceforge.net/pmd-4.3/rules/braces.html
http://bayoubraces.com/
http://www.realself.com/Lingual-braces/reviews
118
Table C.7: Continued
Search
Ranking Website Address
96
97
98
99
100
http://www.sixmonthbraces.com/betamyDentist.asp?Name=Dr.%20R
ichard%20DePaul,%20Jr.&Address=1232%20SOM%20Center%20Rd.,%20
Mayfield%20Hts.,%20OH%2044124,%20USA&Phone=440-6461000&Web=&Whitening=SIXMONTHBRACES
http://gentle-braces.com/
http://www.bracesquestions.com/static/braces-living/bracescare/eating-with-braces/
http://www.braceshop.com/
http://www.braceshop.com/braces-and-supports/elbowbraces/hinged-elbow-braces.htm
Table C.8: Unfiltered Search Results for the Search Term
“orthodontics”
Search
Ranking Website Address
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
http://en.wikipedia.org/wiki/Orthodontics
http://www.braces.org/why-orthodontic-treatment
http://www.braces.org/why-an-orthodontist-for-orthodontics
http://www.braces.org/
http://www.orthodontics.com/
http://www.colgate.com/app/CP/US/EN/OC/Information/Articles/
Cosmetic-Dentistry/Orthodontics/OrthodonticBasics/article/What-is-Orthodontics.cvsp
http://orthodontist.com/
http://www.nlm.nih.gov/medlineplus/orthodontia.html
http://www.orthodontists.com/default.aspx
https://www.aaoinfo.org/
http://dentistry.ucsf.edu/admissions/postgraduateprograms/orthodontics
http://www.americanboardortho.com/public/
http://www.americanboardortho.com/
http://www.cubraces.com/
http://www.wfo.org/
http://dent.osu.edu/ortho/
http://www.americanortho.com/
http://onlinelibrary.wiley.com/journal/10.1111/%28ISSN%29160
1-6343
http://dental.ufl.edu/departments/orthodontics/
http://www.orthodontics.vcu.edu/
119
Table C.8: Continued
Search
Ranking Website Address
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
http://www.dent.umich.edu/aboutschool/department/opd/graduate-program-orthodontics
http://www.atsu.edu/asdoh/programs/orthodontics/
http://dental.columbia.edu/page/postdoctoral-ms-degreeorthodontics
http://www.mylifemysmile.org/glossary
http://www.orthodonticcarespecialists.com/default.aspx
http://www.carlsonortho.com/
http://www.orthodontic.org/
http://louisville.edu/dentistry/residency/orthodontics
http://www.vanderbilthealth.com/dental/31023
http://www.urmc.rochester.edu/Dentistry/education/orthodonti
cs.aspx
http://www.uthsc.edu/dentistry/Grad/Ortho/
http://devdent.uthscsa.edu/orthodontics/postdoc.asp
http://www.mvorthodontics.com/
http://jorthod.maneyjournals.org/
http://www.angle.org/
http://www.uic.edu/depts/dort/ortho.html
http://www.sciencedirect.com/science/journal/08895406
http://www.ucdenver.edu/ACADEMICS/COLLEGES/DENTALMEDICINE/PR
OGRAMSADMISSIONS/GRADUATEPROGRAMORTHODONTICS/Pages/GraduateP
rogramOrthodontics.aspx
http://ejo.oxfordjournals.org/
http://www.ju.edu/orthodontics/Pages/default.aspx
http://www.jco-online.com/
http://sparkorthodonticsschuylkill.com/
http://orthocj.com/
http://www.garrettsmiles.com/
http://www.ohsu.edu/xd/education/schools/school-ofdentistry/about/academic-departments/orthodontics/
http://aiortho.com/
http://www.lsusd.lsuhsc.edu/fsortho.html
http://www.orthodonticcarega.com/
http://www.propelorthodontics.com/
http://www.opalorthodontics.com/Pages/default.aspx
http://bcd.tamhsc.edu/education/ortho/
https://www.dentistry.iu.edu/index.php/departments/orthodont
ics-and-oral-facial-genetics/orthodontics/
http://www.pickardortho.com/
https://www.dentistry.unc.edu/academic/ade/ortho/
http://www.merriam-webster.com/dictionary/orthodontics
http://www.i-ortho.com/
http://www.kaysvilleutorthodontist.com/
120
Table C.8: Continued
Search
Ranking Website Address
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
http://individualortho.com/
http://dental.tufts.edu/academics/orthodontics/
http://dental.pacific.edu/Academic_Programs/Graduate_Orthodo
ntics_Program.html
http://www.webmd.com/oral-health/orthodontics-bracesdirectory
http://dental.case.edu/orthodontics/
http://www.miller-ortho.com/
http://www.deerwoodorthodontics.com/
http://www.bnbraces.com/
http://www.yourdentistryguide.com/orthodontics/
http://www.fairfieldorthodontist.com/
http://www.dryanosky.com/
http://dental.washington.edu/orthodontics/
http://www.bluestoneorthodontics.com/
http://www.campbellsmiles.com/default.aspx
http://www.maneyonline.com/loi/jor
http://solutions.3m.com/wps/portal/3M/en_US/orthodontics/Uni
tek/
http://www.journals.elsevier.com/american-journal-oforthodontics-and-dentofacial-orthopedics/
http://www.orthodontic-associates.com/
http://www.garnerorthodontics.com/chandler-orthodontist
http://familyorthodontics.com/
http://www.classiccityorthodontics.com/
http://www.sadlerorthodontics.com/
http://www.dentistry.uiowa.edu/orthodontics
http://www.gladwellorthodontics.com/
http://www.mouthhealthy.org/en/az-topics/b/braces
http://www.saortho.org/
http://www.hilgersorthodontics.com/
http://www.bgbraces.com/default.aspx
http://www.sabaortho.com/
http://www.bishoporthodontics.com/
http://www.beorthodontics.com/
http://mccormickorthodontics.com/
http://brunerortho.com/
http://www.mkorthodontics.com/
http://www.minnesotaorthodontics.com/
http://www.lyonsorthodontics.com/
http://www.neso.org/
http://www.db.uth.tmc.edu/education/advanced-educationprograms/orthodontics
121
Table C.8: Continued
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Ranking Website Address
96
97
98
99
100
http://www.oltjenbraces.com/
http://www.lucasorthodonticgroup.com/
http://www.daviesortho.com/
http://www.halgrenorthodontics.com/
http://www.texasorthodontics.com/
122
VITA AUCTORIS
Chelesa Phillips was born on November 14, 1985 in
Houston, Texas. She is the first child of Joseph and Cleo
Phillips and the proud sister of Jovel Phillips.
Chelesa graduated from Westfield High School in
Houston in 2004. She then attended Washington University in
St. Louis, where she obtained a Bachelor of Arts in Biology
in 2008 with a minor in Anthropology. She obtained her
Doctor of Dental Surgery degree from Howard University in
Washington, DC in May of 2012. From there, she returned to
St. Louis to begin the orthodontic residency program at
Saint Louis University, where she is currently a candidate
for the degree of Master of Science in Dentistry.
Upon her graduation in December of 2014, Dr. Phillips
plans to work in the Greater New Orleans area as the
orthodontic provider for a chain of clinics specifically
catering to underserved children. She is excited about this
next step in her life with Mike and Kamo and is happy to be
closer to her parents at home and far, far away from the
snow and winter in general.
123