Original Article

Characterizing the orthodontic research literature: 2020

David W. Chambersa

ABSTRACT
Objectives: To characterize features of the current orthodontic literature.

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Methods and Materials: All research articles published in 2020 (N ¼ 350) in the American Journal
of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, and the European Journal of
Orthodontics were categorized on 48 features such as type of study (domain of generalization,
subjects, and research design), analytical tools (statistical tests, power and normality of data,
consistency of measurement, management of covariables, and corrections of multiple independent
tests), and reporting characteristics. Consistency of the coding was high (j . .990).
Results: The ‘‘most typical’’ article was a cohort study reporting multiple patient outcomes at a
single treatment location. Soundness of analyses was uneven, with about half providing information
on power or normality of the data and consistency of measurement. Few articles addressed
covariables or adjusted for multiple tests of independent outcomes. Photos and flow charts were
commonly used to explain methods, and results were presented in multiple formats. There was a
clear association between design and reporting characteristics and type of study for systematic
reviews, meta-analyses, and case reports. There were small but consistent differences across the
three journals.
Conclusions: The quality of the orthodontic research literature has advanced at an uneven pace,
and this review identifies areas that could be strengthened. Substantial gaps remain in achieving
accepted standards for randomized controlled trials and opportunities exist for better understanding
measures of effect through design and analysis using regression techniques to identify sources of
variance. (Angle Orthod. 2023;93:228–235.)
KEY WORDS: Research design; Reporting; Standards; Questions

INTRODUCTION (ANOVA) is no longer considered an advanced

statistical test. Computer programs now model latent
Orthodontic research has changed significantly in
variables (patterns), and published articles themselves
the past 50 years. Ethical standards for studies
have become dependent variables in systematic
involving patients became formalized as a result of
reviews (SRs) and meta-analyses (MAs). All of this
the Belmont Report in the United States, the Declara-
has been accompanied by publication standards such
tion of Helsinki in Europe, and elsewhere in the world.
as Consolidated Standards of Reporting Trials (CON-
Increased funding from governments and industry SORT) and Preferred Reporting Items for Systematic
prompted more scholarship. Electronic storage and Reviews and Meta-Analyses (PRISMA) that identify
key-word retrieval eased the entry of residents and best practices. Documenting key changes is important
first-time scholars. A one-way analysis of variance for strengthening the science base, providing context
to reviewers and editors, alerting those who teach
a
Professor, Department of Diagnostic Sciences, Arthur A. residents about needed skills, and signaling to
Dugoni School of Dentistry, University of the Pacific, San
Francisco, Calif, USA. practitioners how researchers are using more sophis-
Corresponding author: David W. Chambers, Professor, ticated approaches.
Department of Diagnostic Sciences, Arthur A. Dugoni School There is literature critiquing various shortcomings in
of Dentistry, University of the Pacific, 155 Fifth Street, San the field. Examples include conflict of interest, 1
Francisco, CA 94103, USA
(e-mail: [email protected]) retracted articles,2 conformance with reporting stan-
dards such as CONSORT for randomized controlled
Accepted: July 2022. Submitted: April 2022.
Published Online: October 20, 2022 trials (RCTs)3–9 and SRs,10,11 focus group reporting,12
Ó 2023 by The EH Angle Education and Research Foundation, power (sample size) estimates,13,14 cohort studies that
Inc. test against baseline,15,16 and country of authorship.17,18

Angle Orthodontist, Vol 93, No 2, 2023 228 DOI: 10.2319/041222-285.1

ORTHODONTIC RESEARCH LITERATURE: 2020 229

An exhaustive survey was performed of three journals proportion of space devoted to various sections of the
during the year 2020 to quantify the topics, research articles, number of references, and country of authors.
methods, analytical approaches, and conventions for The results of analyses were reported in contingency
describing materials and methods and reporting tables as counts and percentages. Chi-square analy-
findings. This is an update of previous studies,3,19 the ses, or Fisher exact tests in the case of small expected
most recent having covered studies reporting data 7 values, were performed. Intrarater consistency was
years previously. estimated by Cohen’s kappa for the two codings of all
variables for all articles by the author and by Fleiss’s
MATERIALS AND METHODS kappa for interrater reliability using a random sample of
20 characteristics for 10 articles coded by four raters.
The sample included all articles published in 2020 in

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the American Journal of Orthodontics and Dentofacial RESULTS
Orthopedics (AJO-DO), The Angle Orthodontist (An-
gle), and the European Journal of Orthodontics (EJO). The data set contained 16,800 data points (48
There were 172 articles in AJO-DO (10 of which were categories for 350 articles). Interrater consistency
in digital-only format), 100 articles in Angle, and 78 was j ¼ .995; interrater consistency was j ¼ .867.
articles in EJO. Combining the most frequently occurring features in
Coding categories were developed based on review the data set, the ‘‘typical’’ orthodontic article published
of articles in the June (or second) 2019 issues of each in AJO-DO, Angle, and EJO in 2020 had the following
journal. Adjustments were made in the coding template characteristics: a retrospective analysis of patient
based on reading and coding the August (or fourth) records at a single site to determine whether any of
issue in that year. The coding on which this analysis multiple measured occlusal outcomes differed across
was based was conducted throughout 2020 as each treatment. About half of the studies reported power
issue became available. All articles were coded twice calculations or checks for normality of data, and half
by the author with the second coding used for analysis. did not report the consistency of data capture. The t-
The coding template is shown in Table 1. Some test for differences between two means was the most
characteristics were coded in mutually exclusive common statistical test. A variety of ways of describing
categories. For example, each study was classified the materials and methods and displaying the results
as involving humans, animals, or previously published was used. Tables of numerical findings were very
literature. Where appropriate, multiple categories were common. Flow charts and forest plots were strongly
marked present, absent, or not appropriate when associated with SRs or MAs, and before and after
multiple characteristics could be present. An example photos were ubiquitous in case reports. Together,
would be cases in which more than one statistical test materials and methods and results comprised 70% of
was performed for a study. each article, with about 10% devoted to introducing the
Three groups of features were coded for each issues studied. There was an average of nearly 35
published article. Studies were grouped by type of references per article. Contributions were published
research question. This included the nature of the from researchers around the world.
research question (treatment effectiveness, perception
or measurement issues, biology, case studies, and Study Type
SRs, for example), research design (clinical trials, As shown in Table 2, almost 60% of articles drew
sample descriptions, quantification of variance contrib- conclusions regarding changes in occlusion attribut-
uted by various factors, and consistency of measure- able to treatment interventions. The smallest category
ment approaches, for example), and subjects (patients was biology studies, with 5% of the articles. AJO-DO
in treatment, general population, tissues, animals, or had the largest proportion of articles describing
passes with phantoms, what was counted in determin- population characteristics. Angle offered proportionally
ing sample size). Type of analysis, the second major more reports on treatment effects. EJO presented
coding characteristic, included enumeration of the more science regarding the biological characteristics of
various statistical tests performed. Also counted were orthodontics (v2 ¼ 24.83, df ¼ 8, P ¼ .002, u ¼ 266).
the presence of data management practice such as Table 3 summarizes the results concerning the unit
power tests and tests for normality of data, covariable of analysis. More than three-quarters of articles
handling, and estimates of consistency of measure- generalized to the individual human, usually a patient.
ment. The third major group of characteristics identified When tissues, animals, mathematical models, or
were concerned with reporting. This included use of phantoms were used, this was labeled ‘‘nonpersons,’’
photos, tables, flow charts, and figures in the presen- and these accounted for 145 of the studies (41%).
tation of the study design and for presenting findings, Secondary analyses comprised about 10%. These

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230 CHAMBERS

Table 1. Coding Categories for Characteristics of Articles Appearing in 2020 in AJO-DO, Angle, and EJO
Type of Study (All Classifications Are Mutually Exclusive in Each Category)
Domain of generalization: What kinds of practices or decisions do results apply to?
Treatment effects: Does treatment X make a difference?
Population characteristics: What proportion of children in a community have condition X?
Perceptions: Do patients and orthodontists agree on what a beautiful smile looks like?
Measurement: Are digital landmark locations consistent with human judgment?
Biology: Is the presence of X cells different following treatment?
Subjects, unit of analysis: What are the components of N?
Patients treated at a single site
Patients treated at multiple sites
Nontreatment accompaniments of care

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Communities not in treatment
Tissue
Animals (primarily rats)
Mathematical models
Phantoms
Studies in the literature
Research design: How are data organized for inferential tests?
Cohort: Two or more naturally occurring groups, retrospective
Matching: Single cohort chose, then subjects as nearly as possible on some points selected, retrospective
Clinical trial: Prospective comparison of outcomes across created groups, prospective
Randomized controlled trial: Clinical trial where participants are assigned on randomization of some features, prospective
Regression: Estimates of variance contributed by various sources
Systematic reviews/meta-analysis: Analysis of selected published articles/estimation of common effect given selected articles
Case: Reports of status of individual patient from diagnosis through treatment
Observation: Description of characteristics in naturally occurring group
Latent structure: Computerized identification of patterns in data where input or outcomes are not naturally observable entities
Analysis (all items scored yes/no/NA)
Power test Statistical tests
Test for parametric variables t-test for two means
Management of covariables Nonparametric test for two means
Correction for multiple dependent variables v2
Consistency check on measurement Correlation coefficient
ICC One-way ANOVA
Dahlberg Repeated-measures ANOVA
j N-factorial ANOVA
Bland-Altman Multiple regression
t-test Latent structure
Percent agreement Content analysis
Needed but none performed
Reporting
Material and methods sections (yes/no/Not Applicable) Results (yes/no/Not Applicable)
Numerical data regarding sample Numerical data on outcome variables
Patients, equipment, intervention Bar graph
Measurement, landmark location Chart, scatterplot, survival
Flow chart Box and whiskers
Before and after photo
Forest plot
Bias threat table
Chart data for cases
Inches of text Country of authors
Introduction United States, Canada
Materials and methods Europe, Australia
Results, including tables and figures Asia
Discussion, limits, conclusion Middle East
South America
Number of references

were SRs and MAs where previously published articles Table 4 displays studies by research design.
were the unit of analysis. EJO reported fewer studies Retrospective studies, at 32%, and studies using latent
with patients as the unit of analysis and more structure or regression designed to explain observed
secondary work (v2 ¼ 17.47, df ¼ 4, P ¼ .001, u ¼ .223). outcomes, were used in 28% of publications. Prospec-

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ORTHODONTIC RESEARCH LITERATURE: 2020 231

Table 2. Domain of Generalization in Articles Published in 2020 in

Three Orthodontic Journalsa
AJO-DO Angle EJO Total
Treatment effects 56.4 65.0 57.7 59.1
Population characteristics 15.7 7.0 7.7 11.4
Perceptions 14.5 8.0 12.8 12.3
Measurement features 12.2 15.0 9.0 12.3
Biology 1.2 5.0 12.8 4.9
N 172 100 78 350
a
Values are percentages of articles per journal in each category.

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tive and descriptive studies of naturally occurring
populations each accounted for about 20%. AJO-DO
was less likely to publish research with prospective
designs and Angle less likely to publish observational
studies. EJO was less apt to publish observational or
retrospective research. It did not publish any case
studies in 2020 (v2 ¼ 36.49, df ¼ 6, P , .001, u ¼ .323). Figure 1. Breakdown of randomized controlled trials by type of
conclusions and subject.
As shown in Figure 1, RCTs to test interventions to
improve patient occlusion accounted for 9% of the
published articles. Prospective designs were well Parametric and nonparametric tests for differences
represented (about one-third of studies) but used between two means were used in almost half of the
reported work. Other common tests were chi-square,
about twice as often for research with animals,
correlation coefficient, one-way ANOVA, and regres-
modeling, tissue, or phantoms (v2 ¼ 20.96, df ¼ 1, P
sion analysis. Less common were tests for complex
, .001, u ¼ .060).
experimental designs such as repeated-measures
ANOVA, N-factorial ANOVA, and latent structure
Study Analysis
methods.
Integrity of the data sets and statistical tests are
shown in Table 5. Power tests and tests for parametric Study Reporting
properties of data appeared in fewer than half of the Use of graphic and tabular presentations of infor-
studies where these would have been appropriate. The mation in the materials and methods section and
effect of covariables (such as age and sex of patients) results section of articles are displayed in Table 6. In
on tested outcomes was considered in few cases and almost half of the studies, diagrams were used to help
tested in only 7%. One-third of the studies had multiple readers understand landmark and measurement loca-
dependent variables. This was especially true for tions. In about a quarter each, flow charts and pictures
cohort studies at 55%. Almost no studies reported of equipment were presented. Consistent with the
make appropriate corrections. The Bonferroni adjust- underreporting of covariables, data on characteristics
ment is simple, but conservative. Multiple analysis of of the sample other than independent and dependent
variance (MANOVA) is preferred when it can be variables were presented in fewer than 10% of cases.
performed. Tables showing average and standard deviation

Table 3. Subjects, Units of Analysisa

AJO-DO Angle EJO Total AJO-DO Angle EJO Total
Patients, single site 53.5 60.0 32.1 50.6 Individuals 81.9 76.0 64.1 76.2
Patients, multiple sites 5.8 3.0 24.4 9.1
Patients, nontreatment 8.1 8.0 3.8 7.1
Communities 14.5 5.0 3.8 9.4
Tissue 1.2 4.0 2.6 2.3 Nonperson 11.6 18.0 17.8 14.3
Rats, dogs 3.5 2.0 9.0 4.3
Mathematical models 1.7 10.0 2.6 4.3
Phantoms 5.2 2.0 1.3 3.4
Literature 6.4 6.0 20.5 9.4 Secondary 6.4 6.0 20.5 9.4
N 172 100 78 350
a
Values are percentages of articles per journal in each category.

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232 CHAMBERS

Table 4. Research Designa

AJO-DO Angle EJO Total AJO-DO Angle EJO Total
Observation 25.5 13.0 9.0 18.3 Observation 25.5 13.0 9.0 18.3
Cohort 13.4 28.0 16.7 18.3 Retrospective 33.8 36.0 21.8 31.7
Matching 4.7 2.0 5.1 4.0
Case 15.7 6.0 0.0 9.4
RCT 11.0 25.0 30.8 19.4 Prospective 13.3 30.0 32.1 22.3
Clinical trial 2.3 5.0 1.3 2.9
Regression 20.3 15.0 17.9 18.3 Explanatory 27.2 21.0 37.1 27.8
Reviews, meta-analysis 5.2 6.0 19.2 8.6
Latent structure 1.7 0.0 0.0 0.9
N 172 100 78 350

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a
Values are percentages of articles per journal in each category.

scores for various classifications of the outcomes were materials and methods; 48.7 for results; and 28.3 for
common in every applicable case (80% overall). These discussion, limitations, and conclusions. Graphics
were supplemented with bar graphs, scatterplots, and were measured in inches in their appropriate sections.
sometimes box-and-whisker diagrams where tests The typical article had 33.4 references. The shortest
were performed on differences between group aver- discussion sections (averaging 29.0 inches) were
ages or associations among variables. The second found in EJO (v2 ¼ 31.24, P , .001), and the fewest
most common way of reporting outcomes (about one- references (averaging 28.0) were found in Angle (v2 ¼
third of the cases) was by using photographs. The 19.30, df ¼ 2, P , .001, u ¼ 055).
expected use of data reporting associated with type of
project was observed. For example, forest plots always DISCUSSION
appeared for MAs, bias tables were very common for
SRs, and before and after photos and patient chart This survey demonstrated the richness of the
information always accompanied case reports. orthodontic literature. The range of issues addressed
Several demographics features of the literature were and the research methods used to understand them
also recorded. A total of 1025 author names appeared are reflective of a profession that is evolving and has
on the 350 publications. These were categorized in five not yet settled into rituals of inquiry. ‘‘Definitive
geographic regions. Almost one-third (31%) of authors experiments,’’ those intended to establish irrefutable,
were from Europe, followed by Asia (21%), the United ‘‘yes/no’’ answers to research questions were rare. For
States and Canada (18%), Latin America (16%, almost the most part, we are looking over the shoulders of
entirely from Brazil), and the Middle East (14%, mostly practitioners in academic settings who are showing us
Turkey and a few from India). EJO featured more what they have been exploring. The refinements of
articles from European authors (v2 ¼ 24.32, df ¼ 4, P , power calculations, management of covariables, and
.001, u ¼ .069). adjustments for multiple hypothesis testing are un-
All three publications used a two-column, 8.5 3 11 evenly applied. Several decades ago, these were not
format so it was possible to compare allocation of text matters for consideration. The sophistication of statis-
to sections, measured in inches. The averages were tical tests also shows strong recent advances. Ortho-
10.1 column inches for the introduction; 45.5 for dontic research is now international.

Table 5. Design Features and Statisticsa

Integrity of the Data Statistical Tests
Power test performed 42.6 t-test for means 27.7
Test for parametric variables 41.8 Nonparametric for means 18.9
Management of covariables 16.5 v2 15.7
Multiple dependent variables 1.1 Correlation coefficient 15.1
Measurement consistency 51.7 One-way ANOVA 18.0
ICC 33.3 Repeated-measures ANOVA 04.6
Dahlberg 13.9 N-factorial ANOVA 07.1
j 9.0 Multiple regression 16.0
Bland-Altman .6
t-test 5.2 Latent structure 02.7
Percentage agreement .7 Content analysis 00.6
a
Values are percentages of those cases where such tests are appropriate.

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ORTHODONTIC RESEARCH LITERATURE: 2020 233

Table 6. Reporting
Materials and Methods Results Unusual Valuea
Characterization of sample 7.7 Numerical tables 78.9 69.8 AJO-DO***
Equipment, intervention 25.1 Bar graphs 20.9 33.8 RCTs***
Measurement, landmarks 47.7 Charts, scatterplots 24.9 34.4 observations***
Flow charts 27.7 Box and whiskers 5.4
Photos, before/after 31.7 20.5 EJO**; 78.8 cases***
Forest plots 4.0 9.0 EJO*; 43.3 SRs***
Bias threats table 4.0 46.7 SRs***
Chart data for cases 7.1 75.8 cases***
a
‘‘Unusual Value’’ identifies cases where a statistically significant result was found using the v2 analysis. The unusual value shows cases

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where the observed and expected values differ widely.
* P , .05; ** P , 01; *** P , .001.

Strengthening of Standards this research, 52% of articles reported measurement

consistency. The distribution of methods was compa-
Study standards are beginning to appear regularly,
rable. Satisfaction with the quality of RCTs and
such as CONSORT for reporting RCTs; STROBE for
summary reporting in orthodontics generally tended
observational studies; COREQ for qualitative studies;
to group in the mediocre range, with slightly less than
PRISMA for reporting SRs; and Grading of Recom-
half of articles meeting reviewers’ criteria.5–9 A recent
mendations Assessment, Development, and Evalua-
trend called ‘‘RCT spin’’ has been identified where
tion and AMSTAR for critiquing them. But these were
authors claim in the materials and methods section to
not as widely evident as were forest plots for MAs and
before-and-after images for case presentations. have used high levels of research design that cannot
be confirmed in the results section. Flint and Harrison5
Literature About the Literature placed the proportion of ‘‘spin RCTs’’ at 42%. Harrison7
put it at 55%. The review article by Koletsi et al.21 in the
The findings in this summary were generally Journal of Evidence-Based Practice reported that only
consistent with the articles exploring individual features 40% of claimed RCTs they reviewed met the criteria. In
in the literature. Baumgartner et al.19 also studied AJO- the current study, articles were classified as RCT if the
DO, Angle, and EJO, retrospectively, prior to 2012 and authors labeled them as such, but studies claiming to
found that AJO-DO reported cases but Angle and EJO randomly assign subjects to treatment conditions were
carried more ‘‘research’’ articles. Bearn and Alharbi3 very rare. Chen et al.4 reviewed five leading orthodontic
reported a different order for publishing research journals in 2019 and reported that the top level of
articles in the period 2008 through 2012, with Angle evidence, using the GRADE system, was achieved in
being the least scholarly. Pandis and colleagues9 only 1% of articles analyzed.
presented an overview article in the Journal of Dental
Research characterizing ‘‘publication waste’’ as ‘‘insuf- Opening the Question
ficient information to make clear decisions.’’ They
found adequate sample size calculations in no more Recent attention in the secondary literature focused
than 36% of studied articles, adequate randomization on strengthening the RCT model to enhance protection
in no more than 68%, and management of covariables of claimed treatment benefits from bias. Claims for
in fewer than 43% of studies. Koletsi et al.13 reported differences between groups were the most common
that sample sizes were inadequate in 71% of the study reported in the literature sampled. However, these
studies they reviewed. Seehra et al.14 found adequate were usually retrospective and performed at a single
sample size calculations in only 52% of the articles. In location, perhaps with a single operator or common
the current study, power tests were performed in 43% protocol for patient selection. Analysis of variance tests
of the cases, and management of covariables was (including the t-test and its nonparametric versions)
observed in 17%. Seehra et al.14 also reported that were the most popular form of statistical analysis, and
52% of studies of treatment outcomes used only often, multiple such tests were applied to a single study.
single-site data, 23% were prospective, 19% retro- Although calls for improving this model are appropriate,
spective, and 53% used cohort designs. In the current the CONSORT standard is actually silent on this
article, these numbers were 83%, 63%, 27%, and 37%. approach. Instead, it is urged that measures of effect
Donatelli et al.20 reported that 47% of the articles they be reported to quantify the anticipated impact of
reviewed in five orthodontic journals reported consis- intervention on outcomes of interest.
tency of measurement, with intraclass correlation More than a quarter (28%) of the 2020 articles
coefficient (ICC) being the most common method. In studied used a regression approach intended to

Angle Orthodontist, Vol 93, No 2, 2023

234 CHAMBERS

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Angle Orthodontist, Vol 93, No 2, 2023