Specialist orthodontics in the General Dental Service

The Scottish Orthodontic Peer Review project: the outcome of treatment and standard of record keeping by orthodontic specialist practitioners in Scotland

OBJECTIVES

Assess occlusal outcomes of treatment and clinical record keeping in specialist practice in Scotland.

DESIGN

A retrospective cohort study.

SETTING

Specialist practices in Scotland.

PARTICIPANTS

Specialist orthodontists in Scotland.

METHODS

Every specialist practitioner in Scotland (51) was invited to take part in the peer review project with 38 (76%) enrolled. Scotland was split into four geographical areas, and each practitioner matched with a colleague from the same area. Practitioners took one day to visit their colleague and score 30 consecutively treated NHS cases using the Peer Assessment Rating (PAR) index. They also assessed the quality of the records taken. Practitioners then swapped roles and assessed their partner's occlusal outcomes and records.

RESULTS

The mean pretreatment PAR score was 28.6 (SD 3.5). Mean posttreatment PAR score was 3.5 (SD 1.2). Mean reduction in PAR score was 25.1 (SD 3.8). Mean percentage PAR score reduction was 87.7% (SD 3.7%). Overall record keeping scores were written records 100%, study models 99.5%, Orthopantomogram radiograph 99.2%, photographs 86.3%, medical history 75% and consent 40.8%.

CONCLUSIONS

Occlusal outcomes achieved by specialist practitioners in Scotland were of a high standard. They maintained a good standard of clinical record collection in most areas examined.

Practical aspects to undertaking research in the primary care setting: experience from two studies

AIMS

To discuss the practical aspects of conducting research in a primary care setting, from the perspectives of the practitioner and the research team.

METHODS

Various issues are discussed, including the relevance of research questions being generated in this setting, the advantages to both parties and the processes involved in conducting a study in specialist practice. This paper describes two recent studies (a randomized clinical trial and a qualitative study) conducted within specialist practice, to illustrate some of the potential difficulties.

CONCLUSIONS

The success of conducting a study in primary care is determined by a variety of factors, including an interested specialist practitioner, motivated staff in a well-organized practice and the close support of an academic-based research team.

Orthodontic treatment with fixed appliances in the General Dental Service in Scotland

The records of 128 subjects treated by orthodontic specialists with fixed appliances in the General Dental Service in Scotland were randomly selected from the Scottish Dental Practice Board for analysis. The results of the study revealed that: (1) Mean post-treatment Peer Assessment Rating was 7.8 +/- 4.6 PAR points. (2) Mean reduction in PAR score was 14.9 +/- 10.6 PAR points. (3) Mean percentage reduction in PAR was 59 per cent. (4) Twenty-eight per cent of the cases were 'greatly improved', 15 per cent of the cases were made 'worse or no different'. (5) Median duration of treatment was 15 months, with a range of 2-41 months. (6) Multiple regression analysis showed that 82 per cent of the variability of PAR change could be predicted by the pretreatment PAR scores and the number of arches treated. Post-treatment PAR scores and duration of treatment could not be predicted with adequate reliability. It was concluded that although about 75 per cent of the cases were treated to at least acceptable alignment and occlusion, the modest average percentage reduction in PAR score could be explained by the low average initial PAR score and the borderline need for treatment in many cases.

Retrospective evaluation of the outcome of orthodontic treatment in adults

The aim of this study was the retrospective evaluation of the outcome of orthodontic treatment in consecutively treated adult patients. Of 147 adult patients, it was possible to evaluate the records of 88 patients (57 female, 31 male) before (T1) and after treatment (T2), and of 20 of these patients 3.3 years on average after completion of the retention phase (T3). During treatment planning, a nearly "ideal" result was considered attainable (ideal group) for 46 patients, and a "compromise" result (compromise group) was seen as realistic for 42. The assessment was made using the PAR (Peer Assessment Rating) index and the Aesthetic Component (AC) and Dental Health Components (DHC) of the IOTN (Index of Orthodontic Treatment Need). Average length of treatment in the ideal group was 2.4 years, i.e. nearly twice as long as in the compromise group. The PAR score was reduced by an average of 56% (T2); the reduction in the ideal group was 73%, and in the compromise group 37%. Among the 20 patients for whom at least 6 months had elapsed since completion of the retention phase, a statistically significant relapse between T2 and T3 was observed. The evaluation of overjet and overbite and, in the ideal group, of the midline and maxillary front teeth were primarily responsible for the worsening of the PAR scores between T2 and T3. According to the AC, 53 patients (60%) had moderate to definite treatment needs at the beginning of treatment. Following completion of active treatment, 69 patients (78%) no longer demonstrated treatment indications for aesthetic or psychosocial reasons. Based on the DHC, 88% of the patients were in definite or moderate need of treatment (T1); in contrast, treatment was no longer indicated in 84% at T2. In general, a marked improvement of the examined morphological parameters was observed.

A critical assessment of high-earning orthodontists in the General Dental Services of England and Wales (1990-1991)

Cases from the Dental Practice Board's 2 per cent random sample of completed cases which had been treated by orthodontic practitioners with high gross earnings, were compared to all the cases within the sample from other practitioners. They were assessed using the PAR index and IOTN. High earning orthodontists treated slightly more cases with lower objective need for treatment, but treated no more cases 'Unnecessarily' than other practitioners. They used more fixed appliances, and had marginally better levels of residual need for treatment at finish, although this was at least partially explained by lower levels at start. Generally, their standards were not substantially different to other practitioners. Appliance type had a marked effect on outcome, as did levels of malocclusion and need for treatment at start. Both groups of practitioners performed similarly (better) with dual arch fixed appliances: however, overall standards could only be described as mediocre. There is no justification to single out high earning orthodontists for special scrutiny. However, it may be beneficial if the system of remuneration in the General Dental Services could be modified to give more positive incentive to quality, rather than simply quantity of treatments.

Factors affecting the outcome of orthodontic treatment within the general dental service

Previous studies have suggested large differences in the outcome of orthodontic treatment as measured by the PAR index in two adjacent regions of England. The aim of this prospective study was to identify any factors contributing to the mean PAR score reduction in the North Western region and the Mersey region. Forty-one practitioners submitted 375 sets of start models and 250 end of treatment models. The study ran for 36 months. There were no significant differences detected in the type of malocclusion treated or in outcome of treatment between the two regions with respect to the PAR and IOTN indices. This study did, however, clearly demonstrate that qualified orthodontic practitioners were achieving significantly better results with fixed appliances that practitioners with no orthodontic qualification who used fixed appliances.