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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 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. Bernstein L. Edward H. Angle versus Calvin S. Case: extraction versus nonextraction. Part I. Historical revisionism. Am J Orthod Dentofacial Orthop 1992;102:464-70. Bernstein L. Edward H. Angle versus Calvin S. Case: extraction versus nonextraction. Historical revisionism. Part II. Am J Orthod Dentofacial Orthop 1992;102:546-51. Burrow SJ. To extract or not to extract: a diagnostic decision, not a marketing decision. Am J Orthod Dentofacial Orthop 2008;133:341-42. Peck S, Peck H. Frequency of tooth extraction in orthodontic treatment. Am J Orthod 1979;76:491-6. Weintraub JA, Vig PS, Brown C, Kowalski CJ. The prevalence of orthodontic extractions. Am J Orthod Dentofacial Orthop 1989;96:462-6. Proffit WR. Forty-year review of extraction frequencies at a university orthodontic clinic. Angle Orthod 1994;64:407-14. Janson G, Maria FR, Bombonatti R. Frequency evaluation of different extraction protocols in orthodontic treatment during 35 years. Prog Orthod 2014;15. Proffit WR, Fields HW, Sarver DM. Orthodontic 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. Chapman H. Orthodontics: fifty years in retrospect. Am J Orthod 1955;41:421-42. Wahl N. Orthodontics in 3 millennia. Chapter 2: entering the modern era. Am J Orthod Dentofacial Orthop 2005;127:510-5. Angle EH. Treatment of malocclusion of the teeth: Angle's system. 7th ed. Philadelphia: SS White Manufacturing; 1907. Case CS. The question of extraction in orthdontics. Am J Orthod. 1964;50:658-91. Vaden JL, Merrifield LL. Charles Henry Tweed (18951970). Am J Orthod Dentofacial Orthop 1999;115:333-4. Tweed CH. Indications for the extraction of teeth in orthodontic procedure. Am J Orthod Oral Sur 1944;42:22-45. Begg PR. Stone age man's dentition. Amer J Orthod 1954;40:298-312. 32 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. Bentele M. Orthodontic Extractions. Available at: http://www.inner-smiles.com/ortho-news-articles/ orthodontic-extractions. Accessed on September 9, 2014. Kaidonis JA, Ranjitkar S, Lekkas D, Townsend GC. An anthropological perspective: another dimension to modern dental wear concepts. Int J Dent 2012;2012. Article ID 741405. Stockard CR, Johnson AL. Genetic and endocrinic basis for difference in form and behavior. Philadelphia: The Wistar Institute of Anatomy and Biology; 1941. Little RM, Wallen TR, Riedel RA. Stability and relapse of mandibular anterior alignment-first premolar extraction cases treated by traditional edgewise orthodontics. Am J Orthod 1981;80:349-65. Burke SP, Silveira AM, Goldsmith LJ, Yancey JM, Van Stewart A, Scarfe WC. A meta-analysis of mandibular intercanine width in treatment and postretention. Angle Orthod 1998;68:53-60. Beattie JR, Paquette DE, Johnston LE, Jr. The functional impact of extraction and nonextraction treatments: a long-term comparison in patients with "borderline," equally susceptible Class II malocclusions. Am J Orthod Dentofacial Orthop 1994;105:444-9. Kremenak CR, Kinser DD, Harman HA, Menard CC, Jakobsen JR. Orthodontic risk factors for temporomandibular disorders (TMD). I: Premolar extractions. Am J Orthod Dentofacial Orthop 1992;101:13-20. O'Reilly MT, Rinchuse DJ, Close J. Class II elastics and extractions and temporomandibular disorders: a longitudinal prospective study. Am J Orthod Dentofacial Orthop 1993;103:459-63. History of Extraction/Non-Extraction Debate. Faculté for Orthodontic Research and Continuing Education, Inc. Available at: https://www.forceint.com/courses/sweeping-awaymyths/history-extractionnon-extraction-debate. Accessed on October 24, 2014. Santayana G. The Life of Reason: Reason in Common Sense. Scribner's; 1905. Controversial Topics in Orthodontics: Extraction versus Non-Extraction. Online Guide to Braces. Available at: http://www.bracesguide.com/contoversial/controversial1 .html. Accessed on June 23, 2014. 33 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: part II. Analysis of clinicians' stated reasons for extraction. Am J Orthod Dentofacial Orthop 1996;109:393-402. Vaden JL, Kiser HE. Straight talk about extraction and nonextraction: a differential diagnostic decision. Am J Orthod Dentofacial Orthop 1996;109:445-52. Witzig JW, Spahl TJ. The clinical management of basic maxillofacial orthopedic appliances. Littleton, Mass.: PSG Publishing Co. Inc.; 1987. The Effect of Extractions on the Temporomandibular Joint. Faculté for Orthodontic Research and Continuing Education, Inc. Available at: https://www.forceint.com/courses/ sweeping-awaymyths/effect-extractions-temporomandibular-joint. Accessed on October 24, 2014. Straight Talk. 60 Minutes. 2003. Available at: http://sixtyminutes.ninemsn.com.au/article/259072/stra ight-talk. Accessed on October 3, 2014. Petrisor B, Bhandari M. The hierarchy of evidence: Levels and grades of recommendation. Indian J Orthop 2007;41:11-5. Rushing SE, Silberman SL, Meydrech EF, Tuncay OC. How dentists perceive the effects of orthodontic extraction on facial appearance. J Am Dent Assoc 1995;126:769-72. Bowman SJ. More than lip service: facial esthetics in orthodontics. J Am Dent Assoc 1999;130:1173-81. Luppanapornlarp S, Johnston LE, Jr. The effects of premolar-extraction: a long-term comparison of outcomes in "clear-cut" extraction and nonextraction Class II patients. Angle Orthod 1993;63:257-72. Paquette DE, Beattie JR, Johnston LE, Jr. A long-term comparison of nonextraction and premolar extraction edgewise therapy in "borderline" Class II patients. Am J Orthod Dentofacial Orthop 1992;102:1-14. Basciftci FA, Usumez S. Effects of extraction and nonextraction treatment on class I and class II subjects. Angle Orthod 2003;73:36-42. Kim E, Gianelly AA. Extraction vs nonextraction: arch widths and smile esthetics. Angle Orthod 2003;73:3548. Bishara SE, Jakobsen JR. Profile changes in patients treated with and without extractions: assessments by lay people. Am J Orthod Dentofacial Orthop 1997;112:639-44. 34 40. 41. 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. Stephens CK, Boley JC, Behrents RG, Alexander RG, Buschang PH. Long-term profile changes in extraction and nonextraction patients. Am J Orthod Dentofacial Orthop 2005;128:450-7. Bowman SJ, Johnston LE, Jr. The esthetic impact of extraction and nonextraction treatments on Caucasian patients. Angle Orthod 2000;70:3-10. Erdinc AE, Nanda RS, Dandajena TC. Profile changes of patients treated with and without premolar extractions. Am J Orthod Dentofacial Orthop 2007;132:324-31. Bokas J, Collett T. Effect of upper premolar extractions on the position of the upper lip. Aust Orthod J 2006;22:31-7. Gryson JA. Changes in mandibular interdental distance concurrent with rapid maxillary expansion. Angle Orthod 1977;47:186-92. Isiksal E, Hazar S, Akyalcin S. Smile esthetics: perception and comparison of treated and untreated smiles. Am J Orthod Dentofacial Orthop 2006;129:8-16. Johnson DK, Smith RJ. Smile esthetics after orthodontic treatment with and without extraction of four first premolars. Am J Orthod Dentofacial Orthop 1995;108:162-7. Gianelly AA. Arch width after extraction and nonextraction treatment. Am J Orthod Dentofacial Orthop 2003;123:25-8. Kundinger KK, Austin BP, Christensen LV, Donegan SJ, Ferguson DJ. An evaluation of temporomandibular joints and jaw muscles after orthodontic treatment involving premolar extractions. Am J Orthod Dentofacial Orthop 1991;100:110-5. Dorfman HS. Mucogingival changes resulting from mandibular incisor tooth movement. Am J Orthod 1978;74:286-97. Artun J, Krogstad O. Periodontal status of mandibular incisors following excessive proclination. A study in adults with surgically treated mandibular prognathism. Am J Orthod Dentofacial Orthop 1987;91:225-32. Yared KF, Zenobio EG, Pacheco W. Periodontal status of mandibular central incisors after orthodontic proclination in adults. Am J Orthod Dentofacial Orthop 2006;130:6.e1-8. 35 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. Controversial Topics in Orthodontics: Can extraction of teeth be avoided with expansion?. Online Guide to Braces. Available at: http://www.bracesguide.com/ contoversial/ controversial2.html. Accessed on June 23, 2014. Boley JC, Mark JA, Sachdeva RC, Buschang PH. Long-term stability of Class I premolar extraction treatment. Am J Orthod Dentofacial Orthop 2003;124:277-87. Housley JA, Nanda RS, Currier GF, McCune DE. Stability of transverse expansion in the mandibular arch. Am J Orthod Dentofacial Orthop 2003;124:288-93. Damon D. Three keys to non-extraction therapy. Ortho Tribune 2006;1:13-4. Angle EH. Art in relation to orthodontia. Proc Am Soc Orthod 1902. Internet usage statistics: the internet big picture. Internet World Stats. Available at: http://internetworld stats.com/stats.htm. Accessed on September 20, 2014. Internet. Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Internet. Accessed on September 29, 2014. Deshpande A, Jadad AR. Trying to measure the quality of health information on the internet: is it time to move on? J Rheumatol 2009;36:1-3. Web 2.0. Wikipedia, the free encyclopedia. Available at: http://en.wikipedia.org/wiki/Internet. Accessed on September 29, 2014. Aldairy T, Laverick S, McIntyre GT. Orthognathic surgery: is patient information on the Internet valid? Eur J Orthod 2012;34:466-9. Gordon MM, Capell HA, Madhok R. The use of the Internet as a resource for health information among patients attending a rheumatology clinic. Rheumatology (Oxford) 2002;41:1402-5. Butler L, Foster NE. Back pain online: a crosssectional survey of the quality of web-based information on low back pain. Spine (Phila Pa 1976) 2003;28:395-401. Chestnutt IG. The nature and quality of periodontal related patient information on the world-wide web. Br Dent J 2002;193:657-9. van der Marel S, Duijvestein M, Hardwick JC, et al. Quality of web-based information on inflammatory bowel diseases. Inflamm Bowel Dis 2009;15:1891-6. 36 66. 67. 68. 69. 70. 71. 72. 73. 74. 75. Antonarakis GS, Kiliaridis S. Internet-derived information on cleft lip and palate for families with affected children. Cleft Palate Craniofac J 2009;46:75-80. Cohen RA, Stussman B. Health information technology use among men and women aged 18-64: Early release of estimates from the National Health Inteview Survey, January-June 2009. Health E-Stats. National Center for Health Statistics. 2010. Available at: http://www.cdc.gov/nchs/ data/hestat/healthinfo2009/healthinfo2009.htm. Accessed on June 9, 2014. Fox S. Online health search 2006. Pew Research Internet Project. Pew Research Center. 2006. Available at: http:// www.pewinternet.org/2006/10/29/onlinehealth-search-2006/. Accessed on September 30, 2014. Berland GK, Elliott MN, Morales LS, et al. Health information on the Internet: accessibility, quality, and readability in English and Spanish. JAMA 2001;285:2612-21. Proffit WR, Fields HW, Sarver DM. Malocclusion and dentofacial deformity in contemporary society. In: Proffit WR, Fields HW, Sarver DM, editors. Contemporary orthodontics. 4th ed. St. Louis: Mosby; 2007. p.3-6. Harris poll shows number of "cyberchondriacs" - adults who have ever gone online for health information increases to an estimated 160 million nationwide. Harris Interactive. 2007. Available at: http://www.harrisinteractive.com/vault/ HarrisInteractive-Poll-Research-Cyberchondriacs-2007-07 .pdf. Accessed on October 2, 2014. Stinson JN, Tucker L, Huber A, et al. Surfing for juvenile idiopathic arthritis: perspectives on quality and content of information on the Internet. J Rheumatol 2009;36:1755-62. de Boer MJ, Versteegen GJ, van Wijhe M. Patients' use of the Internet for pain-related medical information. Patient Educ Couns 2007;68:86-97. Jadad AR, Gagliardi A. Rating health information on the Internet: navigating to knowledge or to Babel? JAMA 1998;279:611-4. Gagliardi A, Jadad AR. Examination of instruments used to rate quality of health information on the internet: chronicle of a voyage with an unclear destination. BMJ 2002;324:569-73. 37 76. 77. 78. 79. 80. 81. 82. 83. Bernstam EV, Shelton DM, Walji M, Meric-Bernstam F. Instruments to assess the quality of health information on the World Wide Web: what can our patients actually use? Int J Med Inform 2005;74:13-9. Wilson P. How to find the good and avoid the bad or ugly: a short guide to tools for rating quality of health information on the internet. BMJ 2002;324:598602. Smith R. The invention of talk. BMJ 2002;324. Ansani NT, Vogt M, Henderson BA, et al. Quality of arthritis information on the Internet. Am J Health Syst Pharm 2005;62:1184-9. Baker L, Wagner TH, Singer S, Bundorf M. Use of the internet and e-mail for health care information: Results from a national survey. JAMA 2003;289:2400-6. Kunst H, Groot D, Latthe PM, Latthe M, Khan KS. Accuracy of information on apparently credible websites: survey of five common health topics. BMJ 2002;324:581-2. Smart JM, Burling D. Radiology and the internet: a systematic review of patient information resources. Clin Radiol 2001;56:867-70. Patel U, Cobourne MT. Orthodontic extractions and the Internet: quality of online information available to the public. Am J Orthod Dentofacial Orthop 2011;139:e103-9. 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 References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Bernstein L. Edward H. Angle versus Calvin S. Case: extraction versus nonextraction. Part I. Historical revisionism. Am J Orthod Dentofacial Orthop 1992; 102:464-70. Bernstein L. Edward H. Angle versus Calvin S. Case: extraction versus nonextraction. Historical revisionism. Part II. Am J Orthod Dentofacial Orthop 1992;102:546-51. Burrow SJ. To extract or not to extract: a diagnostic decision, not a marketing decision. Am J Orthod Dentofacial Orthop 2008;133:341-42. Proffit WR. Forty-year review of extraction frequencies at a university orthodontic clinic. Angle Orthod 1994;64:407-14. Google – Global Market Share on Desktop. NetMarketShare. Available at: http://www. netmarketshare.com/report.aspx?qprid=5&qpaf=&qpcustom =Google+-+Global&qpcustomb=0. Accessed on September 29, 2014. Consumer search internet trends. Experian. Available at: http://www.experian.com/marketing-services/onlinetrends-search-engine.html. Accessed on September 20, 2014. O'Reilly D. Five ways to depersonalize Google search results. 2012. Available at: http://www.cnet.com/howto/five-ways-to-depersonalize-google-search-results/. Accessed on October 3, 2014. Google Click Distribution - How important is Number One? Available at: http://www.ecreativeim.com/blog/ 2011/02/ google-click-distribution-how-important-isnumber-one-position/. Accessed on September 21, 2014. Proffit WR, Fields HW, Sarver DM. Orthodontic 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. Aldairy T, Laverick S, McIntyre GT. Orthognathic surgery: is patient information on the Internet valid? Eur J Orthod 2012;34:466-9. Antonarakis GS, Kiliaridis S. Internet-derived information on cleft lip and palate for families with affected children. Cleft Palate Craniofac J 2009;46: 75-80. 85 12. 13. 14. 15. 16. 17. 18. Ni Riordain R, McCreary C. Head and neck cancer information on the internet: type, accuracy and content. Oral Oncol 2009;45:675-7. Eysenbach G, Kohler C. How do consumers search for and appraise health information on the world wide web? Qualitative study using focus groups, usability tests, and in-depth interviews. BMJ 2002;324:573-7. Ansani NT, Vogt M, Henderson BA, et al. Quality of arthritis information on the Internet. Am J Health Syst Pharm 2005;62:1184-9. Chestnutt IG. The nature and quality of periodontal related patient information on the world-wide web. Br Dent J 2002; 193:657-9. Ni Riordain R, McCreary C. Dental patients' use of the Internet. Br Dent J 2009;207:583-6. Rose S, Bruce J, Maffulli N. Accessing the Internet for patient information about orthopedics. JAMA 1998; 280:1309. Ling CA. Guiding patients through the maze of drug information on the Internet. Am J Health Syst Pharm 1999; 56:212-4. 86 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. 92 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 Search 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 Search 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 Search 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 Search 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