The Journal of EVIDENCE-BASED DENTAL PRACTICE

REVIEW ANALYSIS & EVALUATION

LIMITED EVIDENCE SUGGESTS THAT A

HISTORY OF SUBOPTIMAL BREASTFEEDING
MAY INCREASE THE RISK OF DEVELOPING
ANTERIOR OPEN BITE, POSTERIOR
CROSSBITE, AND CLASS II CANINE
RELATIONSHIP
REVIEWER
CARLOS FLORES-MIR
Do optimal breast-feeding habits decrease the risk of developing malocclusions in the primary dentition?

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION SORT SCORE

Malocclusion in young children. Does breast-feeding really reduce the risk? A
A B C N/A
systematic review and meta-analysis. Do
gramacı EJ, Rossi-Fedele G, Dreyer CW. SORT, Strength of Recommendation Taxonomy.
J Am Dent Assoc 2017; 148(8):566-74.

LEVEL OF EVIDENCE
1 2 3
SUMMARY See page 9A for complete details regarding SORT and LEVEL OF
EVIDENCE grading system.

Selection Criteria
The study requirements for inclusion were (1) sample of young children without
previous orthodontic treatment or craniofacial surgical procedure; (2) exposure SOURCE OF FUNDING
consisting of breastfeeding (any breastfeeding compared to the absence of it) Australian Government Research
exclusivity vs no exclusivity, and breastfeeding duration; (3) outcome such as Training Program Scholarship
overjet, overbite, crossbite, or posterior interocclusal relationships; and (4) study
type consisting of cohort, case–control, or analytical cross-sectional studies.
TYPE OF STUDY/DESIGN
Key Study Factor Systematic review with meta-analysis
Breast-feeding details (timing and frequency) and malocclusion details (occlusal of data
relationships) had to be included. Regarding breastfeeding, ideally, they sought
for how long it was sustained and at what point, other forms of feeding were
incorporated. For malocclusion, no overall malocclusion diagnosis was adopted, KEYWORDS
but instead researchers focused on specific malocclusion traits that could be Breastfeeding, Malocclusion,
reasonably associated with breast-feeding practices. Primary dentition

Main Outcome Measure

The main outcome measure is increased risk of developing malocclusion traits.
Specifically, this meant developing a mismatch in the bite between the upper and J Evid Base Dent Pract 2018: [79-81]
lower dentition.
1532-3382/$36.00
ª 2017 Elsevier Inc.
Main Results All rights reserved.
Seven studies were included from an initial potential number of 36 after the first doi: https://doi.org/10.1016/
screening phase. All were considered to have a reasonable methodological j.jebdp.2017.12.004

March 2018 79
 The Journal of EVIDENCE-BASED DENTAL PRACTICE
quality (as per Joanna Briggs Institute [JBI] guidelines).
Random-effects model meta-analysis was applied when
possible. No publication bias analysis was justifiable. Results
were significant for anterior open bite (relative risk: 1.44;
95% confidence interval: 1.15-1.81 for those without
breastfeeding), posterior crossbite (for those without exclu-
sive breastfeeding–no numerical synthesis provided), and
class II canine relationship (relative risk: 1.66; 95% confi-
dence interval: 1.39-1.98 for those with shorter breast-
feeding period). Evidence for other malocclusion traits was
inconclusive. The authors did in-depth analysis of identified
inconsistencies in the original samples as potential reasons
for confusing results.
Conclusions
Children who more adequately breastfed did not have the
same risk for developing malocclusion traits as those who
did not. Increased risk of developing anterior open bite,
posterior crossbite, and class II canine relationship was seen
among young children with a history of suboptimal
breastfeeding.
COMMENTARY AND ANALYSIS
Optimal breastfeeding has been suggested to provide sig-
nificant overall health benefits in growing children. There
are some claims that it also helps with proper craniofacial
development. This comprehensive and well-executed sys-
tematic review with associated meta-analysis attempts to
shed some light on this controversial topic. The strengths
and limitations were well noted by the authors. Discussion
was ample and useful. Several important points were raised,
and the reader is left with significant points to consider.
Based on the stated limitations, the proposed conclusions
are adequate. In summary, children who more adequately
breastfed did not have the same risk than those who did
not. Increased risk of developing anterior open bite, pos-
terior crossbite, and class II canine relationship was found
among young children with a history of suboptimal
breastfeeding.
There are several points that I would like to raise. The authors
claim that the effect of breastfeeding on primary dentition
malocclusion development has not been synthesized before.
This is incorrect, as 2 previous systematic reviews about this
association were available at the time of the search.1,2 It is
puzzling that while executing a comprehensive evidence-
based search they would not have popped up. In addition,
a new one has recently been published.3 I believe that it is
important for the interested reader to check those 3
additional resources to obtain a more comprehensive
picture of our current knowledge. Although the review by
Peres et al.1 considered malocclusion at any age, almost all
the included studies were from the primary dentition. The
80 Volume 18, Number 1
review by Abreu et al.2 focused on primary and mixed
dentition malocclusions. Interestingly enough, Peres et al.1
supported a potential preventive action by proper breast-
feeding practices, but Abreu et al2 claimed that there was
no enough evidence to support such claim. The most
recent 1 review3 also supports the analyzed systematic
review conclusion that there is a potential association
between breastfeeding and primary dentition malocclusion.
Methodologically, this systematic review had its protocol
approved by the JBI and hence followed its guidelines. This
secured a solid methodological review. Interestingly, the 3
areas of exploration (any breastfeeding compared to the
absence of it, exclusivity vs. no exclusivity, and breast-
feeding duration) were the same approach as in one of
the previously published systematic reviews.1
It is not clear why 12 months was considered the cutoff for
breastfeeding duration grouping. Certainly, an artificial
cutoff number is needed for a dichotomous analysis of a
continuous variable, but some level of justification would
have been nice.
Instead of focusing on malocclusion using the overall angle
malocclusion classification, the authors appropriately
focused on specific malocclusion traits that would be more
likely to be associated with breastfeeding practices (overjet,
overbite, interocclusal relationships, and crossbites).
The use of only higher quality studies for the synthesis is
also a strong point. Initially, any reasonable study type was
included, but then, only the stronger methodological
studies were considered.
In summary, this is a very strong systematic review that
synthesizes well our current knowledge in the area. As
mentioned by the authors, malocclusions are of a multifac-
torial origin so that control of a single environmental vari-
able is unlikely to be the final solution or prevention for
malocclusions.
Clinicians involved with young children should discuss the
potential protective effect of adequate breastfeeding prac-
tices on avoiding or at least diminishing the chances of
facilitating the development of certain malocclusion traits.
Such practices, if executed properly and from an adequate
time frame, would be unlikely to produce adverse occlusal
effects even if not effective. If the potential caries preven-
tion and overall health benefits are considered, then, we all
should be encouraging and promoting breastfeeding, even
though the current level of evidence is not categorical in
implying that suboptimal breastfeeding may increase the
risk of developing anterior open bite, posterior crossbite,
and class II canine relationship.
 The Journal of EVIDENCE-BASED DENTAL PRACTICE

REFERENCES 3. Peres KG, Chaffee BW, Feldens CA, Flores-Mir C, Moynihan P,

Rugg-Gunn A. Breastfeeding and oral health: evidence and
1. Peres KG, Cascaes AM, Nascimento GG, Victora CG.
methodological challenges. J Dent Res 2017; https://doi.org/10.
Effect of breastfeeding on malocclusions: a systematic
1177/0022034517738925. 22034517738925. [Epub ahead of
review and meta-analysis. Acta Paediatr 2015;
print] PubMed PMID: 29108500.
104(467):54-61.

2. Abreu LG, Paiva SM, Pordeus IA, Martins CC. Breastfeeding,

bottle feeding and risk of malocclusion in mixed and permanent
REVIEWER
dentitions: a systematic review. Braz Oral Res 2016;30. https://
Carlos Flores-Mir, DDS, DSc, RCDC(C) Orthodontics
doi.org/10.1590/1807-3107BOR-2016.vol30.0022. Epub 2016 Professor, School of Dentistry, University of Alberta, Canada,
Mar 28. Review. cf1@ualberta.ca

March 2018 81