Comparison of treatment costs and outcome in public orthodontic services in Finland

The objectives of the study were to compare the costs and outcome of orthodontic treatment in eight municipal health centres in Finland. A random sample of the age groups of 16- and 18-year-olds (n = 1109) living in these municipalities was clinically examined by two calibrated orthodontists. The acceptability of the morphology and function of the occlusion were assessed with the Occlusal Morphology and Function Index (OMFI). The data concerning previous orthodontic treatment were collected from the patient records of all subjects (n = 608) who reported previous or ongoing orthodontic treatment or who could not recall if they had received orthodontic treatment. The health centres were grouped into an early and a late timing group according to the mean age of starting the treatment. The mean age for starting orthodontic treatment was 8.0 years (SD 1.9) in the early group and 10.7 years (SD 2.3) in the late group. The visit costs and the costs of orthodontic appliances without overheads comprised the operating costs. The cost-effectiveness of orthodontic services was measured by estimating how much each health centre had to have paid for one per cent unit of acceptable morphology and acceptable function of occlusion. The mean appliance costs were higher in the late timing group and the mean visit costs higher in the early timing group. The mean operating costs per case were €720 in the early and €649 in the late timing group. However, there was a great variation within both groups. The cost of one per cent unit of acceptable morphology was the same in the two timing groups, while the cost of one per cent unit of acceptable function was lower in the early timing group. The low operating costs as such did not totally explain the better cost-effectiveness of orthodontic care. Furthermore, the cost-effectiveness was not directly connected with the timing of treatment.

Is orthodontics an option in the management of bimaxillary protrusion?

Successful orthodontic treatment is based on a clear perception by the clinician of a patient's facial preference and treatment needs. Bimaxillary protrusion is a normal facial trait seen in the Black population and the most acceptable bimaxillary facial profile in a sample of Black subjects was determined by Beukes et al in 2007. Variations from this ideal profile may require extractions as part of orthodontic treatment in order to attain the ideal. The objective of this study was to determine whether Black subjects with bimaxillary protrusion would want to change their facial profile to the ideal and at what financial cost. A sample of 586 school learners and 321 university students were presented with four silhouetted profiles of varying degrees of bimaxillary protrusion. One of the silhouette profiles represented the ideal and treatment procedures required to achieve this ideal were explained to the sample. They were then requested to answer a questionnaire that would assist in identifying their perception of their own profile and their desire to change their appearance. The ideal silhouette was confirmed to be the most attractive (91.51%) and the sample felt that any severe deviations from this ideal profile should be treated. The financial cost of treatment was found to be a concern, as more subjects (62.84%) would undergo the required treatment if it were free. Many subjects (43.55%) would be prepared to pay for the necessary treatment to achieve the ideal profile. Females were found to be more definite in their decision making, reflecting a greater awareness about their aesthetic appearance than their male counterparts. Findings from this study can serve as an essential tool to assist both orthodontists and maxillofacial surgeons in the treatment planning and management of Black patients with bimaxillary protrusion.

Dental ethics case 6. Stalled payment for ongoing orthodontic treatment--balancing responsibilities

It is not always easy for an orthodontist to strike the right balance between a caring, supportive and patient-centered approach, and the need to make a living and to run a profitable business in order to achieve this. Striving to act ethically and professionally at all times will help find this elusive balance and ultimately it will be more rewarding and professionally satisfying. Especially when dealing with children whose lives may be dramatically affected by the interruption or cessation of treatment, orthodontists have a duty to reassure themselves about the financial stability of their contractual relationships with patients or parents. Having consistent financial policies and flexible payment options may assist in this regard. Even in the face of non-payment of fees, treatments that have begun must in some form continue if their cessation would compromise the best interests of patients.

Comparisons of similar patients treated by general dental clinicians and orthodontic specialists. Outcome and economical considerations

The objective of this study was to evaluate and compare orthodontic treatment in two groups of patients in regard to treatment results and costs. One group was treated at a General Dental Clinic (GDC) with removable appliances and the other at a Special Orthodontic Clinic (SOC) using fixed appliances. Both groups had similar malocclusions. All treatment plans were determined bythe same orthodontic specialist. Study models were taken before and after the treatment of the patients. Index of Orthodontic Treatment Need (IOTN-index) was used to determine the extent of treatment needed. Weigthed Peer Assessment Rating (WPAR) was calculated for every model. The percentage of improvement in each group was calculated and results were compared. Chair time and treatment costs extracted from patient records were registered. The group treated at the GDC had initially WPAR 22.2 and the percentage reduction in WPAR 69 was percent.The group from the SOC had initially WPAR 24.0 and was reduced by 81 percent. Treatment costs, with the exception of x-ray analyses, were 56 percent higher for the SOC.The results of the study indicated that it was economically advantageous to treat patients with removable appliances at a GDC, if the patients are sufficiently cooperative.

Orthodontic management of a patient with impacted and transposed mandibular canines

This patient report describes the treatment of a 10-year-old female with complete transposition of her impacted mandibular canines and lateral incisors. The patient had a Class I occlusion, and her mandibular lateral incisors were in crossbite with the maxillary central incisors. The treatment objectives were to create space for the impacted canines and align them with the incisors, one of which was extracted. After treatment, the appearance of the patient's teeth was improved, the occlusion was preserved, and overjet and overbite were corrected.

Uniformity in selection for subsidized orthodontic care--focus on borderline treatment need

In the county of Stockholm, subsidized orthodontic care is offered to roughly 25% of persons under the age of 19. Stockholm County Council has signed contracts with experienced orthodontists (consultants) to carry the responsibility of screening and offering subsidized treatment to those having the most urgent treatment need. For this purpose the orthodontist is free to use whatever yardstick he/she finds most useful. The Swedish Medical Board Index (SMBI) is most commonly used, and was used by the consultants in this study. It is obvious that the selection process under these conditions must be affected by a subjective opinion and consequently the inter-examiner variation would be large, especially for subjects presenting with borderline treatment need. The aim of the study was to evaluate the uniformity in selection of subjects for subsidized orthodontic care with focus on borderline treatment need. Six consultant orthodontists volunteered to participate. Each orthodontist was asked to recruit patients whom they considered to have borderline treatment need. 34 adolescents; 25 girls and 9 boys (mean age 14.5 +/- 1.68 years), were recruited. These patients were individually assessed by each orthodontist. The interexaminer agreement was tested by use of Cohen's kappa statistics (kappa = 0.324). Since all six orthodontists fully agreed in only one third of the cases the validity of the assessments with the present guidelines is insignificant, at least in subjects with borderline treatment need.

Occlusion and orthodontic treatment demand among Chinese young adults in Hong Kong

PURPOSE

The aim of this study was to investigate the occlusion, the demand for orthodontic treatment and the reasons for this among Chinese young adults in Hong Kong.

MATERIALS AND METHODS

A questionnaire was used to study previous orthodontic experience and to evaluate the orthodontic treatment demand and the reasons for this in Chinese university students. Among those who had no orthodontic treatment, 120 participants were invited for an occlusal assessment. Their treatment need was graded using the index of orthodontic treatment need.

RESULTS

A total of 240 students, aged 18 to 27 years, completed the questionnaire survey. Thirty-one students (13%) had orthodontic treatment. Sixty-seven (28%) students had orthodontic treatment demand, and their common reasons were to improve appearance (78%), self-image (36%), self-confidence (34%) as well as to follow parental advice (24%). The reasons for those students who would not consider having orthodontic treatment included no perceived need (64%), long treatment time (18%) and high treatment fee (14%). All 120 invited participants who had no orthodontic treatment attended the occlusal assessment. One-fifth had a normal occlusion. Most malocclusions were manifested as Angle Class I (48%) followed by Class III (21%) malocclusion. Fifty-six students (47%) had moderate and 40 students (33%) had 'great' or 'extremely great' treatment need.

CONCLUSIONS

The most prevalent malocclusion among this group of Chinese young adults was Angle Class I malocclusion. Although the majority of the Chinese young adults had malocclusion with a high treatment need, their demand for orthodontic treatment was relatively low. Apart from consideration of dental health needs, the common reasons for orthodontic treatment demand were influenced by the desire for improvement in appearance.

Socio-economic status and utilisation of orthodontic services in a Nigerian hospital

OBJECTIVE

To study the influence of socio-economic status on the utilization of orthodontic services and the uptake of orthodontic treatment in a Nigerian teaching hospital.

MATERIALS AND METHOD

Relevant information needed for the study had been previously recorded in the patient's case file. A total of 157 patients that presented from December 2002 to December 2004 were reviewed. The socio-demographic data of each patient and all other necessary clinical information were retrieved from the patients case files using a common data abstraction form. The patients were further categorized according to their socio-economic status using a modification of the standard occupational classification system (12). Social Class I represented those with the highest income while social class IV represented those with the lowest income.

RESULTS

Out of the 157 patients that presented during the period of review, 86 (54.8%) were from social class I, 42 (26.7%) from social class II, 22 (14.0%) from social class III and 7 (4.5%) from social class IV. Sixty three percent of the patients presented with skeletal Class I, 23.5% presented with Skeletal Class II, while 13.5% presented with Skeletal Class III, 29.3% of the patients presented with normal over jet and 38.8% patients presented with normal overbite. The Social Class of the patients had a significant effect on the skeletal pattern and overbite (p < 0.05)

CONCLUSION

Majority of patients utilizing Orthodontic services are from the higher social classes, therefore the uptake of orthodontic treatment is mainly a function of cost and not need or demand.

[Orthodontics in general practice 3. Angle Class II/1 malocclusion: one-phase treatment treatment preferred to two-phase treatment]

With regard to the optimal treatment timing for children with an Angle Class II division 1 malocclusion, there is an ongoing controversy on the effectiveness of a two-phase or a one-phase therapy. Two-phase treatment involves a first phase to correct the jaw relationship starting at the age of 7 to 9 years, and, when all permanent teeth are present, a second phase of treatment by fixed appliances. A one-phase treatment involves treatment of the jaw relationship and the dental malocclusion simultaneously or consecutively, starting during the early adolescence period. In recent years, several randomized controlled clinical trials have been performed on this topic. More recently, a Cochrane meta-analysis of these trials has been published. The results show that early treatment of an Angle Class II division 1 malocclusion followed by a second phase of treatment does not have any advantages over treatment that is started later and finished in one phase. One-phase treatment is as effective as two-phase treatment, while the time needed for treatment is shorter and, as a consequence, total costs are lower. Dentists should take into account this information, when treating children with an Angle Class II division 1 malocclusion or referring them to an orthodontist.

Effectiveness of phase I orthodontic treatment in an undergraduate teaching clinic

In this retrospective study, the Peer Assessment Rating (PAR) index was used to objectively evaluate the effectiveness of Phase I (early) orthodontic treatment provided in an undergraduate teaching clinic. Pre-treatment and post-treatment casts of ninety-three patients were analyzed. All patients selected for Phase I orthodontic treatment had Class I skeletal relationships and did not require complex orthodontic treatment such as growth modification or treatment of occlusions with missing or impacted teeth. The mean age of patients who received Phase I orthodontic treatment was 9.9 years. The mean initial PAR score for the sample was 29.70 +/-9.84. The mean reduction in PAR score was 14.9 points corresponding to a 50.2 percent decrease in the PAR score following Phase I orthodontic treatment. Seventy-three percent of the patients experienced at least a 30 percent reduction in their PAR score following Phase I (early) orthodontic treatment. The mean cost of $381.00 for the Phase I orthodontic treatment was found to be influenced by the length of treatment, type of Phase I treatment provided, age at start of treatment, and percentage reduction in PAR score. The greatest success rate for the Phase I orthodontic treatment occurred with either fixed or a combination of fixed and removable appliances. Over half of the patients recommended for Phase I orthodontic treatment in the undergraduate dental clinic were successfully treated and did not require Phase II treatment. For them, there was both a treatment and a financial benefit to the Phase I orthodontic treatment.

Is regular visiting associated with lower costs? Analyzing service utilization patterns in the first nations population in Canada

OBJECTIVES

Using an administrative database of dental service records from the Non-Insured Health Benefits (NIHB) program of Health Canada for 1994-2001, the authors set out to test whether regular visitors had lower program expenditures.

METHODS

The age-specific mean expenditures per client were compared among those with regular examinations in 8, 7 and fewer years. The study further examined the effect of regular visiting over the first 6 years on expenditures in the last 2 years. "Continuity of care" was measured by the numbers of consecutive years prior to 2000 in which clients had a regular examination. In a "gap analysis" individuals were classified according to the number of years prior to 2000 since they last had an initial or recall examination. Mean expenditures per client were analyzed by age group and type of service.

FINDINGS

Over the 8-year period, clients with regular visits had the highest expenditures. In both the continuity of care and gap analyses, the findings were generally consistent; the more that clients visited over the first 6 years, the higher the expenditures in the final 2 years. Clients with more "regular" (initial and recall) examinations received a relatively standard, age-specific, pattern of service but incurred greater expenditures compared to clients with fewer regular, or longer gaps in, examinations.

CONCLUSION

The observations of the authors in this client group do not support the thesis that regular visiting is associated with lower expenditures on dental care.

The problems of borderline cases: an aid for the analysis of orthodontic therapies

Our aim in this analysis was to create a conceptual aid for clinicians for use in dealing with and understanding the problems of borderline cases in general, and in making it easier to make medical and orthodontic treatment decisions. The doctor and patient now have a range of measures available for making a decision.

The equity of access to orthodontic dental care for children in the North East of England

OBJECTIVES

To assess the equity of access to primary care orthodontic treatment in relation to deprivation in the County Durham and Tees Valley Strategic Health Authority area.

STUDY DESIGN

An observational study based on Dental Practice Board data for the County Durham and Tees Valley Strategic Health Authority area with a population of 1.13 million.

METHODS

The postcode of all orthodontic claims made by National Health Service dentists across the area in the financial years 2002/2003 and 2003/2004 were obtained and the claim rate per 1000 at risk population calculated for each ward. These ward rates were then compared to both the level of deprivation measured by the Index of Multiple Deprivation 2000 and the children's dental registration rate of the area.

RESULTS

Inequity in access to orthodontic care was observed. There was a moderate negative correlation r = -0.40 suggesting wards with the lowest claim rates had the greatest deprivation. In addition, the wards with the lowest child dental registration rates also had the lowest claim rates for orthodontic treatment.

CONCLUSIONS

Currently, there is inequity of access to orthodontic treatment for children in County Durham and Tees Valley. The move towards local commissioning for dental services within the NHS will provide an opportunity to reduce inequalities in access.

Nonsurgical treatment of a patient with a Class III malocclusion

A patient with a bilateral Class III molar relationship came to the Department of Orthodontics clinic at Case Western Reserve University. Our first choice for treatment was a combination of orthodontic therapy and orthognathic surgery. The patient, however, opted for a nonsurgical approach that took 34 months and involved the extraction of 4 first premolars and a remaining deciduous tooth, and Class III vertical elastics. Although orthodontic treatment was considered to be a second-line alternative, the results suggest that, for some surgical patients, orthodontic treatment alone might be a better choice because of the favorable cost/benefit ratio.

Malocclusion and uptake of orthodontic treatment in Taranaki 12-13-year-olds

OBJECTIVES

To describe the occurrence of malocclusion and the uptake of orthodontic treatment among 12-13-year-olds in the province of Taranaki, New Zealand.

DESIGN

Cross-sectional descriptive study using a random sample of 12-13-year-olds attending Intermediate schools.

METHODS

Parents or caregivers completed a postal questionnaire. Children (N = 430; participation rate 74.1 percent) completed a questionnaire and were dentally examined.

MAIN OUTCOME MEASURES

Malocclusion, using the Dental Aesthetic Index, or DAI (Cons et al, 1986), recorded by a single calibrated examiner, and the use of orthodontic services as reported by parents or caregivers.

RESULTS

The mean DAI score was 28.3 (sd = 7.8). Females and non-Maori had greater mean DAI scores than males and Maori, respectively. A high proportion of the children needed orthodontic treatment (60.5 percent in the "definite", "severe" or "handicapping" categories), and 17 percent had a "handicapping" malocclusion. While over one-third of the children had been advised to seek an orthodontic consultation, a proportion (23.4 percent) did not. Of those who did, a similar proportion did not proceed with care because of financial considerations. Children of low socio-economic status (SES) were disproportionately represented in these groups. Children with "severe" or "handicapping" malocclusions who did not proceed with treatment came predominantly from low-SES households and high-deprivation areas.

CONCLUSIONS

Cost was a barrier to orthodontic treatment for low-SES, high-deprivation children and Maori. Social and ethnic inequalities exist in orthodontic treatment need in Taranaki. The utilisation of orthodontic treatment appeared to be largely neither equitable nor rational.

A costs analysis of dental treatment for ectodermal dysplasia

OVERVIEW

Dental treatment modalities for ectodermal dysplasia (ED) vary markedly depending on the clinical manifestations, but to date there have been no studies exploring the potential economic impact of ED. On the basis of anecdotal and clinical reports, the authors postulate that costs of dental treatment for this condition can have a substantial financial impact on patients and their families.

OBJECTIVE

The purpose of the authors' pilot study was to develop an economic model for various treatment modalities for ED with severe hypodontia.

METHODS

The authors first used a comprehensive review of the literature and expert consensus to establish a treatment modalities model for ED. Next, they completed chart reviews to validate the model with sample treatment and costs information. Using these data, they then constructed a model of treatment options and associated costs.

RESULTS

The sample included 24 patients with ED who had severe hypodontia. Forty-two percent were female; patients' ages ranged from 4 years, 11 months to 31 years, 1 month. Forty-two percent had dental insurance coverage, while more than one-half paid for services out of pocket. An estimated 84 percent had undergone prosthodontic treatment, 37 percent orthodontic treatment and 19 percent implant surgery. Depending on the age of the patient and types of dental treatment, there was a broad variation in costs. This ranged from $2,038 to $3,298 for those who had received prosthodontic treatment only; it ranged from $12,632 to $41,146 for those who had received a combination of prosthodontic, orthodontic and implant treatment.

CONCLUSIONS

Dental treatment for ED had a marked financial impact on patients and their families and varied depending on the type and duration of treatment.

Public Assistance Orthodontic Treatment Needs: A Report from the State of Indiana

OBJECTIVE

To determine how many of the orthodontic cases covered by Indiana Medicaid between 1999-2001 would be classified pretreatment as having a malocclusion severe enough to warrant treatment.

METHODS

Six examiners were trained and then paired together to examine 249 patient orthodontic case records, consisting either of pre-treatment photographs only, pre-treatment models only, or both pre-treatment models and photos. The examiners applied the Index of Orthodontic Treatment Needs (IOTN) to assign each case a Grade of One to Five, with Grade One representing Ideal Occlusion and Grade Five being Extreme Malocclusion. When two examiners within a pair could not agree, a third examiner reviewed the case record to determine agreement.

RESULTS

Of the 249 patient cases examined, 9 were not gradable. In the cases where only pretreatment models were available (n=157), 10% received a Grade of One or Two (Ideal Occlusion or Mild Malocclusion, respectively). Among the cases in which both pretreatment models and photos were available (n=46), 44% of the photos were graded One or Two, while only 2% of the models were graded as One or Two. In the cases where only pretreatment photographs were available (n=37), 27% of cases were Grade One or Two.

CONCLUSION

While several of the cases (11%) submitted during the time period of 1999 to 2001 to the Indiana State Medicaid Division for reimbursement were rated as having Ideal Occlusions or Mild Malocclusions, the vast majority (89 %) were scored as having either Moderate, Severe, or Extreme Malocclusion.

Measuring the cost, effectiveness, and cost-effectiveness of orthodontic care

AIM

To determine the relative effectiveness and cost-effectiveness of orthodontic treatment per case in one "fee for item" and two different types of salaried orthodontic clinics.

SUBJECTS AND METHODS

This prospective study recruited a random sample of six self-employed orthodontists (fee-for-item) and six orthodontists from both hospital and community clinics (salaried services). One hundred patients were followed to completion of orthodontic care. Questionnaires were employed to determine cost of treatment from the clinicians' and patients' points of views. Four cost-effectiveness models were developed.

RESULTS

Complete records of outcome were available for 1,087 patients, but only 789 had complete data on costing. Three of the four cost-effectiveness models indicated similar rankings for the 18 clinicians. The most cost-effective service was provided by clinicians working in community clinics, followed by clinicians working in hospitals, then self-employed clinicians. The preferred cost-effective model takes into consideration the initial need and successful outcome of orthodontic treatment.

CONCLUSION

Cost-effectiveness models have been developed to quantify the performance of individual clinicians working in self-employed and salaried clinics. Costs and effectiveness of the clinicians in each clinical setting show considerable variation.

Outcome of treatment of Class II malocclusion by intraoral mandibular distraction

Our aim was to find out long-term results of treatment in patients treated orthodontically and by mandibular distraction osteogenesis. Data on duration of treatment, costs, and results of 26 patients (13 girls and 13 boys) with a mean age of 15 years were analysed. The preoperative cephalograms were compared with those taken at the last follow-up visit. There was a significant reduction in duration of treatment when patients were treated without a first phase that included functional appliances. The differences in costs of orthodontic treatment were not significant. The costs of the operation for distraction were significantly higher compared to BSSO, mainly because of the costs of the distraction devices. Comparison of the cephalograms showed a significant increase in SNB angle, Wits value, ANB angle, overjet, and overbite. The Y-axis, MP/S, and SpP/MP angle increased. Orthodontic treatment and distraction of the mandible was a successful, but more expensive, treatment.

Performance measures to improve the quality of orthodontic services and control expenditures

One of the most critical and contentious issues for specialist and nonspecialist professionals in the coming decades will be to evaluate the outcomes of health care services. Performance measures are imperative for elective orthodontics, because of the relatively weak evidence that they lead to significant improvements in dental and oral health, occlusal function, and psychological well-being of patients. Such measures are particularly crucial for orthodontic treatment eligible for benefit payments, because they will assure third-party dental insurers that the annual premiums levied from governments (taxes), employers (in lieu of salary increments), and individuals (in lieu of other discretionary expenditures) are well spent (ie, not wasted). Performance measures will also improve the "standards of orthodontic practice," so the continued integrity of the profession is contingent on their development.

Evaluating the Cost-Effectiveness of Orthodontic Provision

The assessment of orthodontic provision is important to determine if treatment was necessary and undertaken appropriately. The ICON objectively quantifies orthodontic treatment need, complexity and outcome and is a valuable occlusal index in the assessment effectiveness of orthodontic care. It is possible to develop cost-effectiveness models by analysing the costs and effectiveness of orthodontic treatment. Several methods are illustrated to compare the orthodontic provision of specialist orthodontists.

Orthodontic therapy and third party in Europe

This paper is an attempt to individuate some principles and guidelines apt to regulate the relationship between orthodontists and financing third parties, applicable to most western European Countries. The concepts of orthodontic treatment need, orthodontic treatment request and orthodontic screening are discussed, alongside with a short overview of some of the most common indexes to assess the severity of the malocclusion and/or the treatment priority. The screening method introduced by the Danish Ministry of Health is presented; its importance lies in the fact that for the first time a direct correlation between health risk and individual malocclusions is recognized and assessed. In the discussion, it is stressed how the screening system tightly depends on the chosen general model for orthodontic care. Different models of orthodontic care organization as presently used in many European countries are presented and shortly discussed; among these, the Norwegian model is described more in details, because of its simplicity. Eventually, some guidelines considered necessary in order to achieve satisfactory standards of quality and efficiency are presented and discussed.

Distribution of orthodontic services and fees in an insured population in Washington

Previous attempts to quantify the amount and type of orthodontic therapy provided by nonorthodontists in the United States have relied on survey data. Although there are advantages to surveys, such as control over survey recipients and inclusion of specific questions, they also have limitations, such as low response rates, response bias, and recall bias. This study used insurance claims data from a large dental benefits provider in Washington to assess the distribution of orthodontic services and fees among various dental providers. All orthodontic claims allowed by Washington Dental Service in 2001 were retrieved, along with treatment codes, fees, and demographic information for both patients and providers. A total of 102,984 orthodontic claims were included in the study. General dentists submitted 7.0% of these claims, orthodontists submitted 90.9%, and pedodontists submitted 1.9%. Orthodontists submitted higher average fees for space maintainers, first payments, and records. The percentage of orthodontic treatment preformed by general dentists and pedodontists in this claims-based study was substantially less than what has been previously reported in survey-based studies. Additionally, a smaller percentage of general dentists and pedodontists in this study performed comprehensive treatment, compared with previous studies. This study illustrates the value of insurance claims data to assess the provision of orthodontic care.

To what extent do deviations from an ideal occlusion constitute a health risk?

Selection of patients for orthodontic treatment should be based on a thorough analysis of the consequences of malocclusions for the individual. The mere presence of deviations from the concept of the ideal occlusion should have no influence on orthodontic treatment decisions. According to available studies, the influence of malocclusion on periodontal health, speech and chewing is fairly minor. Neither can orthodontic treatment be justified as an effective means of preventing TMD but it may be indicated to reduce existing signs and symptoms of TMD in certain carefully selected cases. Interceptive or preventive orthodontic treatment may be indicated to reduce the negative influence on growth and occlusal development of functional malocclusions (anterior or lateral forced bite) or ectopic tooth eruption. Similarly, early correction of large overjet may be valuable in order to reduce the risk of traumatic injuries. Such treatment is usually motivated during the primary or mixed dentition periods. From the teenage period and onwards, psychosocial or aesthetic reasons for orthodontic treatment are dominating. Decisions to start orthodontic treatment in order to improve aesthetics should usually not be taken before the child has reached sufficient maturity for these decisions, normally after the age of 12 years. Special consideration needs to be given to subjects with craniofacial syndromes or handicap in order to develop effective treatment methods to promote as normal growth and occlusal development as possible.

A critical view of treatment priority indices in orthodontics

Indices for orthodontic treatment prioritization are usually based on morphological and sometimes functional deviations from a concept of an ideal occlusion. However, such morphological variation from a constructed norm only reflects normal biological variation and should never serve as a basis for treatment decisions. Evaluation of treatment need must instead be based on consequences of malocclusion for the subject. Existing indices for orthodontic treatment need focus either more generally on malocclusion or specifically on aesthetics. Aesthetic indices are usually based on some kind of public concensus. In this study, two groups of patients each containing four subjects were selected. Four represented subjects estimated to have malocclusions of average severity (level A), close to a level where selections are usually made. The other four subjects (level B) represented more severe malocclusions reflecting cut-off levels in a system with a more limited budget. The different indices used turned out to offer very little help in the selection of patients and did not reflect the stated ranking of treatment need by seven groups of orthodontists and postgraduate students, all in all 40 persons. Apart from being based on very questionable treatment--motivating factors, these indices cannot serve the basic purpose of creating relevant cut-off points for treatment need.

Relationship of malocclusion severity and treatment fee to consumer's expectation of treatment outcome

Understanding consumer expectations is important if orthodontists are to be successful in marketing their elective services. The purpose of this study was to examine the relationship between consumer outcome expectations and treatment variables, including cost of treatment and malocclusion severity. The subjects were parents of patients recruited from 9 private orthodontic practices in southwestern Pennsylvania who were entering a single comprehensive phase of orthodontic treatment, characterized by a full fee and complete fixed appliances. The parents completed a questionnaire regarding outcome expectations for their child's orthodontic treatment. Pretreatment orthodontic study models of each child were evaluated with the peer assessment rating. The results of this study suggest that orthodontic consumers have very high outcome expectations. Also, the parents of patients with severe overall malocclusions, overjet, or midline deviations have expectations that exceed probable treatment outcomes. Orthodontists should consider that consumers seeking their services have increased expectations not related to the treatment outcomes.

Costs of surgical-orthodontic treatment in community hospital care: an analysis of the different phases of treatment

To determine the distribution of costs and various influencing factors in the entire process of surgical-orthodontic treatment in community hospital care, a retrospective study was carried out. The records and radiographs of 99 community hospital patients operated on between 1994 and 2001 were included. Cost analysis data were gathered from 4 phases of treatment: the orthodontics, the surgical outpatient assessments, the surgery/surgeries, and the inpatient period. The results showed that the surgical phases together are responsible for roughly 61% of the costs, 28% of which were attributed to the surgical operation itself. Orthodontics made up approximately 39% of the total costs, with an average of 26 visits. The average total costs of all treatments were US $6,206 +/- 912. Patients that could be operated on with bilateral sagittal split ramus osteotomy of the mandible only had the lowest costs, and those who required bimaxillary osteotomies had the highest costs. Of the several clinical and cephalometric measurements made in this study, only skeletal open bite and orthodontic space closure after tooth extraction were found to affect the costs. It can be concluded that surgical-orthodontic treatment is a rather expensive way to correct dentofacial malocclusions due to the high costs of the surgical phase. Skeletal open bite constituted the most costly entity, while malocclusion resulting from mandibular deformity was the cheapest.

Subjective need and orthodontic treatment experience in a Middle East country providing free orthodontic services: a questionnaire survey

The aims of this study were to explore orthodontic treatment experience, subjective need for treatment, and perceptions of teeth and dental appearance in relation to background factors such as funding system, area of living, age, gender, ethnicity, and socioeconomic status. The subjects were 1076 randomly selected second-year high school students from a rural (Jahra) and an urban (Capital) area of Kuwait, with a mean age of 15.1 years. Kuwaiti citizens constituted 79% of the sample, and the rest were of other Arab origins. The data were collected using a questionnaire. Orthodontic treatment rate was significantly higher for Kuwaitis (10%) than for non-Kuwaitis (2%). Among Kuwaiti subjects, urban area of living and female gender increased the odds of receiving orthodontic treatment. Subjective treatment need was 36%, with no difference between Kuwaiti and non-Kuwaiti subjects, but Kuwaitis in the rural area expressed subjective treatment need less often than those in the urban area. The results suggest that access to free-of-cost orthodontic treatment was likely to affect treatment rate, whereas it did not seem to influence the self-perceived need for treatment. Gender and area of living may be significant for the distribution of free-of-cost orthodontic treatment.

Determinants of costs of orthodontic treatment in the Finnish public health service

Factors affecting the costs of children's free orthodontic treatment were studied from patient records of a random sample of 193 successfully treated orthodontic patients, aged 7-14 years at the start of the treatment. They were treated by orthodontic specialists in the health centers of the cities of Joensuu, Oulu, and Vaasa. The statistical analysis was done using advanced regression analysis, two-tailed t-test and chi-square test. The results indicated that the number of appliances used, the patients' ages at the start of treatment, the number of missed appointments, differences between health centers, and the change in PAR (Peer Assessment Rating) Index scores accounted for 78.7% of the variations in treatment costs. The number of appliances used was the most important factor in the regression (R2 = 0.657). The costs of treatment were lowest in one-stage treatments started in the permanent dentition, and were highest in two-stage treatments started in the mixed dentition. Significant differences were found in treatment patterns and costs between the three health centers, reflecting low concern for cost-efficiency aspects.

Controlling third-party expenditures and improving quality assurances: a plea for change

Growing demands to contain health care's inflationary expenditures have particular relevance for elective (eg, orthodontic) services, because their progressively increasing provision will ultimately jeopardize the resources for others (eg, restorative dentistry). Some form of rationalization is therefore inevitable, especially in services eligible for payments from third-party benefits. These are central concerns of the ongoing debate on whether rationalization should be driven by service efficiency and cost efficiency and who should make such decisions. The adaptation of contemporary computer-based technology could resolve this dilemma, especially if real-time comprehensive assessments of 3-dimensional craniofacial forms before and after treatment are incorporated into local and national databases. Such a facility would then help to develop clinical guidelines to optimize the provision of specific orthodontic services for particular malocclusions. Referring individual cases to these databases would subsequently help to control service expenditures and maintain or even improve their outcomes to the ultimate benefit of both the profession and the public.

Orthodontic treatment standards in a public group practice in Sweden

The aim was to assess the orthodontic treatment service provided by 6 orthodontists in a group practice in Malmö. One hundred cases were randomly selected from the model store. The Index of Complexity, Outcome and Need (ICON) was used to assess the need, complexity of the problem, outcome, the degree of improvement and whether the completed case was acceptable or not. The reliability of the examiner using the ICON was assessed using Root Mean Square. Logistic regression analysis was employed to explore the variables related to acceptability of the finish and duration of treatment. The younger the patient at the start of treatment the lower initial ICON score, with short treatment duration were associated with an acceptable finish. Three out of 100 cases were deemed as not requiring orthodontic treatment and 36 cases were classified as very difficult to treat. Nevertheless, 71 cases out of the 100 exhibited acceptable finishes with 27 indicating substantial or great improvement. 6 cases finished treatment with ICON scores greater than 43 indicating need for orthodontic treatment. The treatment on average took 22 months. An objective appraisal of the quality of orthodontic care in a group practice in Malmö has been undertaken. Seventy-one cases were completed with acceptable occlusions. The Index of Complexity, Outcome and Need appears to be a valuable tool to assess the multiple facets of orthodontic provision.

Prevalence of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey

Data from the third National Health and Nutrition Examination Survey (NHANES III) provide a clear picture of malocclusion in the US population. Noticeable incisor irregularity occurs in the majority of all racial/ethnic groups, with only 35% of adults having well-aligned mandibular incisors. Irregularity is severe enough in 15% that both social acceptability and function could be affected, and major arch expansion or extraction of some teeth would be required for correction. About 20% of the population have deviations from the ideal bite relationship; in 2% these are severe enough to be disfiguring and are at the limit for orthodontic correction. In Mexican-Americans compared to the rest of the population, incisor irregularity and both severe Class II and Class III malocclusions are more prevalent, but deep bite and open bite are less prevalent. Application of the Index of Treatment Need to the survey data reveals that 57% to 59% of each racial/ethnic group has at least some degree of orthodontic treatment need. Over 30% of white youths, 11% of Mexican-Americans, and 8% of blacks report receiving treatment. Severe malocclusion is observed more frequently among blacks, which may reflect their lower level of treatment. Treatment is much more frequent in higher income groups, but approximately 5% of those in the lowest income group and 10% to 15% of those in intermediate income groups report being treated.

Influence of economic restraints and reduced specialist resources on delivery and quality of orthodontic care

In 1993 and 1994, economic restrictions were introduced in the County of Ostergötland. The aim of this study was to investigate the influence on delivery and quality of orthodontic care, i.e. any subsequent change in number of patients receiving orthodontic treatment both by General Public Dental Service (GPDS) and by specialist clinic, the choice of appliance, and treatment outcomes, and also any changes in the total number of appliance treatments by general practitioners. Records were examined for 236 and 213 patients registered in 1994 and 1997, respectively, at an orthodontic clinic in the western district of Ostergötland. The total number of appliance treatments by general practitioners was estimated. The number of patients receiving initial treatment by a general practitioner and subsequently by an orthodontist, was relatively unchanged during the period. Quad helix predominated in both 1994 and 1997. The best treatment outcomes were achieved by quad helix and maxillary removable appliances, and the poorest by activators and headgear. In conclusion the total number of appliance treatments by general practitioners decreased as well as treatments requiring patient compliance over an extended period, findings which might be a consequence of the coincident economic restriction.

Outcome of a scheme for specialist orthodontic care

With the purpose of examining the outcome of specialist orthodontic care on a population level (Halland, Sweden), a random sample of previously treated 19-year-olds (n=118) was clinically examined and interviewed. Thirty-three per cent of the cohort (n=1554) had received treatment, and mean treatment time was 19 months requiring 20 visits. Changes in occlusion were assessed using the PAR Index applied to dental study casts representing the pre- and post-treatment and follow-up (19 years) condition. The subjects' responses to questions addressing their past and present attitudes to dental appearance and orthodontic treatment were combined to represent "orthodontic concern", at the pre-treatment stage and at 19 years of age. A mean reduction in weighted PAR scores of 83% was observed from pre-treatment to post-treatment, whereas at follow-up, the net improvement was 69%. A significant shift in attitudes was observed, as 72% of the individuals expressed orthodontic concern pre-treatment compared to less than 10% at 19 years. The improvement obtained was similar to other studies on outcome of orthodontic treatment provided by specialist orthodontists. Compared to most PAR-studies providing information about orthodontic services, the present scheme appeared to be efficient on the assumption that duration of treatment and number of visits are expressions of costs.