Letters From Our Readers
To: Editor, The Angle Orthodontist.
Re: Response to: Influence of reminder therapy for controlling bacterial plaque in patients undergoing orthodontic treatment: a systematic review and meta-analysis. Lima IFP, de Andrade Vieira W, de Macedo Bernadinho I, Costa PA, Lima APB, Pithon, MM, Paranhos LR. The Angle Orthodontist. 2018, 88(4): 483-493.
We would like to thank the author's interest in our systematic review.1 These opportunities for debate are relevant and to be encouraged. In this specific case, the generated discussion allows all of us to better understand how to assess the level of scientific evidence and strength of recommendations.
We had a few concerns when we decided to apply the GRADE tool,2 considering that it has not been extensively utilized in systematic reviews published so far in the field of Orthodontics. One of our concerns was to find the best means of assessing the overall results instead of just individual study risk of bias assessment. However, we only acquired such understanding after reading the most recent paper on the new instructions of use for the GRADE tool, which was published after the acceptance of the present systematic review.3 The author's assessment of the flaws in our interpretation and use of the GRADE tool is correct.
Regarding the question about the risk of bias, it was also our concern when assessing the eligible studies. There is no consensus on the best means of assessing risk of bias in systematic reviews, and the literature presents different approaches and validated tools. This is a source of confusion.
In the present systematic review, we performed the risk of bias assessment in pairs as suggested by the JBI Critical Appraisal Checklist for Randomized Controlled Trials. The forest plots were constructed using Review Manager, version 5.3 software (Rev-Man; Cochrane Collaboration, London, United Kingdom) based on the data extracted from each individual study and following the instructions to conduct a meta-analysis. We agree that heterogeneity was high and so we stated in the discussion of the systematic review that the results should be interpreted with caution.
Another systematic review recently published also found results similar to ours and the authors claimed that reminder therapy may be a valuable tool to improve the oral hygiene of patients undergoing orthodontic treatment.4 This topic of the literature was also a recent target of comments in a review synthesis performed by other authors.5
Lastly, we thank the author once again for her interest in our systematic review and the fact that she raised pertinent questions in the letter to the editor.