Development of a treatment outcome standard as a result of a clinical audit of the outcome of fixed appliance therapy undertaken by hospital-based consultant orthodontists in the UK

Orthodontic treatment protocol versus Peer Assessment Rating: Assessing the quality of orthodontic treatment

OBJECTIVE

To apply the Peer Assessment Rating (PAR) to cases that have been assessed by the NHS Business Service Authority (NHSBSA) using the orthodontic treatment protocol (OTO), then compare the NHSBSA outcome assessment with weighted (W) and unweighted (U) PAR scores.

DESIGN

Cross-sectional study.

SETTING

UK.

CASES

Anonymised orthodontic cases submitted to the NHSBSA.

METHODS

A sample of 30 reports from 2021/2022 were randomly selected to include different standard of treatment grades. The records were de-identified and the pre- and post-treatment study models were PAR scored by a calibrated assessor.

RESULTS

The mean percentage change in PAR was higher in cases from green reports (W: 78%; U: 79%) than amber (W: 68%; U: 67%) and red reports (W: 65%; U: 65%). Alignment and poor buccal segment interdigitation were the most reported concerns for cases included in the red and amber graded reports. A residual increased overjet was the most common occlusal feature leading to PAR scores not being more than 70% improved. Only slight agreement was shown between OTP and PAR using the kappa statistic, and the chi-square statistical test found that outcome measures are statistically significantly different.

CONCLUSION

There are fundamental differences between OTP and PAR, and general agreement between them has not been demonstrated. The NHSBSA Report provides a more critical outcome assessment than PAR, identifying elements that are not assessed or measured by the PAR index.

Clinical audit of orthodontic chart documentation by dental undergraduates

INTRODUCTION

Clinical audit is a quality improvement process that seeks to improve patient care and outcomes through the systematic review of care against explicit criteria and the implementation of change. The objective of this audit was to evaluate the quality of orthodontic chart documentation by dental undergraduates against established guidelines.

MATERIALS AND METHODS

An audit checklist with 13 criteria for good documentation was adapted from guidelines proposed by the American Association of Orthodontists and British Orthodontic Society. Orthodontic chart documentation in 103 removable appliance therapy patients under 4th and 5th year dental undergraduates' care was retrieved from the electronic record of the University dental clinic and audited. The audit exercise explored in detail the thirteen criteria for good documentation and eight assessment attributes of the first criterion, namely, basic orthodontic examination. The level of compliance was measured as the percentage records meeting the criteria. The data were statistically analysed using SPSS 26.0 (SPSS, Inc., Chicago, IL, USA).

RESULTS

There was no complete compliance for any of the criteria. Thirty-five (33.9%) patient charts reported basic orthodontic examination documentation adequately. Compliance was the highest for documentation of treatment modality (77.6%), appliance delivery encounters (77.6%), and appliance adjustment appointments (83.5%). About 51.4% of the 68 patient charts (treatment of 35 patients of the total 103 were in the progress stage) stated adequately the outcome of treatment. Only 22% of the 68 patient charts had the details for retention protocol. There was statistically significant difference in chart documentation between male and female students for basic orthodontic assessment and appliance delivery and patient instructions attributes.

CONCLUSION

The clinical audit demonstrated poor compliance with the criteria for orthodontic chart documentation. The audit should be repeated after the provision of learning opportunities and self-critical analysis.

Peer Assessment Rating (PAR) scoring of cleft patients treated within a regional cleft centre in the United Kingdom

OBJECTIVE

To assess static occlusal outcomes for patients with cleft lip and/or palate (CLP) and cleft palate (CP) managed within a UK Regional Cleft Service and to compare with previously published Peer Assessment Rating (PAR) scores from a non-cleft population of patients treated within a UK consultant-led hospital service.

DESIGN

Retrospective multicentre study.

SETTING

Eight orthodontic hospital units within the Spires Cleft Service, UK.

PARTICIPANTS

Patients born with CLP or CP between 1985 and 1995 treated within the service.

METHODS

Patients were assigned to groups by cleft type and whether they were treated by orthodontics only or a combination of orthodontics and orthognathic surgery. PAR was recorded before and after treatment from study models.

RESULTS

Data were collected for 171 patients included in the study. Median pre-treatment PAR was 42 and post-treatment 11. Median percentage change in PAR for all patients was 73%, although 12% of cleft patients had a PAR improvement that was worse or no different. Median change in PAR score was 71% for those treated with orthodontics only and 83% for those who had an osteotomy. Median PAR improvement for those treated with orthodontics only was 73% in the cleft lip group, 77% in the CP group, 66% in the unilateral CLP group and 53% in the bilateral CLP group. Median pre- and post-treatment PAR for the cleft group was higher and PAR reduction lower than those published for non-cleft patients.

CONCLUSION

These data demonstrate high severity of malocclusion, complexity of orthodontic treatment and difficulty in achieving an ideal static occlusion for cleft patients. If PAR is to be used to assess orthodontic outcomes in cleft patients the findings of this study should be considered. A higher proportion of cases are likely to be classed as 'worse or no different', and a lower percentage change will be expected.

Patient reported experiences and treatment outcomes of orthodontic patients treated within secondary care settings in the South West of England during the COVID-19 pandemic

OBJECTIVE

To assess the impact of the temporary cessation of orthodontic services on patients undergoing treatment during the COVID-19 pandemic.

DESIGN

Two-phase multicentre service evaluation.

SETTING

Secondary care orthodontic departments in the South West of England.

MATERIALS AND METHODS

Phase 1 - Patient-Reported Experience Measure questionnaire (PREM). The questionnaire was distributed to patients who had undergone orthodontic treatment during the COVID-19 pandemic once services had resumed. Phase 2 - assessment of treatment outcomes, specifically with the Peer Assessment Rating (PAR) Index. A total of 280 PAR scores were obtained from a cohort of patients treated before and during the pandemic.

RESULTS

A total of 711 PREM questionnaires were completed. Participants generally felt relaxed when visiting secondary care settings, orthodontic departments and whilst wearing orthodontic appliances during the pandemic. Nearly 40% of participants were concerned that the pandemic would impact on their treatment, particularly treatment length. Treatment outcomes revealed that patients treated before and during the pandemic experienced percentage PAR score reductions of 83.9% and 80.6%, respectively. Patients receiving treatment during the pandemic experienced longer treatment durations of 126 days.

CONCLUSION

During the pandemic, low levels of anxiety were reported with respect to receiving orthodontic treatment in secondary care settings. Irrespective of the pandemic, a high standard of orthodontic treatment was provided. However, patient concerns regarding treatment length were justified.

Occlusal Outcome of Orthodontic Treatment for Patients With Complete Cleft Lip and Palate

AIM

To assess occlusal outcomes of orthodontic treatment for patients with complete cleft lip and palate.

DESIGN

Retrospective assessment using the Peer Assessment Rating (PAR) index.

SETTING

Consecutive patients treated by one consultant orthodontist at a tertiary care cleft center.

PARTICIPANTS

One hundred twenty-seven patients with either complete unilateral cleft lip and palate (UCLP) or bilateral cleft lip and palate (BCLP) consecutively treated with fixed appliances.

INTERVENTION

Fixed orthodontic appliance treatment and orthognathic surgery when required.

OUTCOMES

The PAR index assessment was carried out by a calibrated-independent assessor. Treatment duration, the number of patient visits, and data on dental anomalies were drawn from patient records and radiographs.

RESULTS

One hundred two patients' study models were assessed after exclusions. Mean start PAR score for UCLP (n = 71) was 43.9 (95% CI, 41.2-46.6, SD 11.5), with a mean score reduction of 84.3% (95% CI, 81.9-86.7, SD 10.1). The UCLP mean treatment time was 23.7 months with 20.1 appointments. Mean start PAR score for BCLP (n = 31) was 43.4 (95% CI, 39.2-47.6, SD 11.4), with a mean score reduction of 80.9% (95% CI, 76.3-85.5, SD 12.5). The BCLP mean treatment time was 27.8 months with 20.5 appointments.

CONCLUSION

These results compare well with other outcome reports, including those for patients without a cleft, and reflect the standard of care provided by an experienced cleft orthodontist. As with high-volume surgeons, orthodontic treatment for this high need group is favorable when provided by a high-volume orthodontist. These findings may be used for comparative audit with similar units providing cleft care.

An audit of ‘early debond’ cases in the national outcomes audit of patients treated with upper and lower fixed appliances by Consultant Orthodontists in the UK

OBJECTIVE

To audit the outcomes of the 'early debond' cohort of the national outcomes audit carried out by the Consultant Orthodontic Group of the British Orthodontic Society.

DESIGN

Multi-centre, retrospective national audit.

STANDARDS

Seventy-five per cent of cases should exhibit a reduction in PAR greater than 70% with 3% or less with a PAR score reduction of less than 30% (i.e. worse/no different).

METHOD

Analysis of consecutively completed cases treated by upper and lower fixed appliances that were noted by the operator as having discontinued treatment early.

MAIN OUTCOME MEASURES

Incidence of early debond, PAR outcome.

RESULTS

The 'early debond' cohort constituted 11% of the total 823 patients and fell below previously published standards for orthodontic treatment outcomes. They were less likely to be in the 'greatly improved' category, more likely to be in the 'improved' category and only slightly more likely to be in the 'worse/no different' category. There was a 67% reduction in PAR and 50% exhibited a reduction in PAR greater than 70%, with 6.5% having a reduction in PAR score lower than 30%.

CONCLUSION

Discontinuation of orthodontic treatment is associated with a reduced level of treatment outcome.

Psychosocial predictors of affect in adult patients undergoing orthodontic treatment

In this paper we propose to study the role of psychosocial variables in affect in adult patients undergoing orthodontic treatment, considering that affect is a key variable in treatment adherence. Seventy-four patients (average age 33,24 ± 10,56) with metal multibracket-fixed orthodontic treatment were included. Patients were assessed twice. The first stage, at the beginning of treatment, included assessment of dental impact (Psychosocial Impact of Dental Aesthetics Questionnaire), trait anxiety (State-Trait Anxiety Inventory), self-esteem (Rosenberg's self-esteem scale), and self-efficacy (General Self-efficacy Scale). In the second stage, 6 months later, positive and negative affect towards treatment was assessed using the Positive and Negative Affect Scale. Dental social impact differentiates between patients with high and low negative affect, while self-efficacy differentiates between patients with high and low positive affect. Trait anxiety and self-esteem differentiate between both types of affect (positive and negative). Trait anxiety and self-esteem (when trait anxiety weight is controlled) are significant predictor variables of affective balance. These results have important practical implications, because it seems essential to adopt a bio-psychosocial model incorporating assessment methods focusing on day-to-day changes in mood and well-being.

What are the occlusal outcomes for unilateral cleft lip and palate patients? A national project in the UK

AIM

This national project assessed the orthodontic outcome for unilateral cleft lip and palate (UCLP) patients in the UK.

METHOD

Six consecutively treated fixed appliance cases where orthognathic surgery was not undertaken were assessed using the peer assessment rating (PAR) index on orthodontic study models. These cases were submitted by NHS consultant orthodontists undertaking treatment on patients with cleft lip and/or palate.

SETTING

UK NHS consultant-led hospital service.

RESULTS

The mean reduction in PAR score was 69% + or - 22. The mean start PAR score was 41 + or - 11. The mean end of treatment PAR was 12 + or - 9. The proportion of cases where the score was worse or no different was 7.5%.

CONCLUSION

The mean percentage PAR reduction compares well with other national projects looking at outcome from patients treated in the hospital service. The mean PAR reduction could be used as a benchmark for outcome in UCLP orthodontic treatments in future audit projects and the annual consultant appraisal process.

Are the Peer Assessment Rating Index and the Index of Treatment Complexity, Outcome, and Need suitable measures for orthognathic outcomes?

The aim of this study was to determine which of two occlusal indices were the most appropriate for use in the assessment of orthognathic outcome. The indices used were the Peer Assessment Rating (PAR) Index and the Index of Treatment Complexity, Outcome, and Need (ICON). These indices were validated against the subjective assessments of treatment outcome and treatment improvement obtained from a panel of experienced orthodontic consultants. For the subjective assessment, intraexaminer agreement for ranking treatment outcome, from patient study models (30 models), was good. Interexaminer agreement for ranking treatment outcome, in the same way, was good or moderate. Intraexaminer agreement for ranking treatment improvement (30 start and finish pairs of models) was very good or good. Interexaminer agreement for ranking treatment improvement ranged from good to fair. All the patient study models were scored using PAR and ICON. The level of correlation between PAR and ICON scores of treatment outcome and the subjective ranking of treatment outcome was significant (P < 0.001). The level of correlation between PAR and ICON scores of treatment improvement and the subjective ranking of treatment improvement was also significant (P < 0.001). It is concluded that both PAR and ICON are suitable indices for assessing the clinical outcome of combined orthodontic treatment and orthognathic surgery.