Decision aids against overuse of orthodontic services?

Development and evaluation of a patient decision aid for young people and parents considering fixed orthodontic appliances by Marshmann et al. (2016). J Orthod. 43:276-287. The development of the first fixed appliance decision aid (FADA) may be an enormous advancement in improving the quality of orthodontic care (Marshmann et al. 2016). The importance of the work arises especially from the fact that decision aids may facilitate the shared decision-making process by means of providing up-todate scientific evidence on benefits and harms if presented in an appropriate format and at a right time point during the patient-physician communication. That is to say, through better information and better understanding, FADA may strengthen patient autonomy which is the fundament of bioethics and professional ethics. As we read through the study however, we have certain doubts that authors conclusion that the FADA provides patient-relevant information, a hallmark of decision aids, probably cannot be drawn from this study. According to the criteria of the International Patients Decision Aids Standards (IPDAS), relevant treatment options presented in the decision aids have to include also the ‘comprehensive, critically appraised, and up-to-date syntheses of the scientific evidence’ (IPDAS 2012). However, according to the section Methods of the study, the authors did not conduct any systematic review and critical appraisal of the available evidence to inform the content of FADA. For example the FADA’s content on root resorption, white spot lesions and patient experience were supported by only few selected single studies without clear selection criteria (Marshmann et al. 2016). Yet if the FADA fails to include some up-to-date and critically appraised evidence it may misinform patients (ethical dimension), cause unnecessary treatments (quality of care dimension) and thus resulting in more harm than good (Montori et al. 2013). We are aware of the difficulties associated with providing up-to-date scientific evidence for available treatment options, often limited funding, time consuming appraisal of literature, or low quality of available systematic reviews, just to mention a few. However, those limitations should be explicitly mentioned in the study so readers may be aware of them when drawing conclusion from the results. Also, strategies have been suggested to overcome the limitations of traditional decision aids and they could be useful in developing the FADA (Agoritsas et al. 2015). To conclude, the authors made a first and probably most important step toward strengthening patient autonomy, given that the content and the presentation of the FADA is truly evidence-based. In orthodontic care, where probably misinformation and subsequent excessive overtreatment are common (Ackermann 2010; Spassov et al. 2015), decision aids may be one valuable strategy to overcome those problems that may causes unnecessary harm and costs to patients and society