b) Summary of Promotion Paper

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b) Summary of Promotion Paper

  1. 1. RIGA STRADIŅŠ UNIVERSITY Andra Liepa Assessmentof orthodontic treatment need and effectiveness (speciality - orthodontics) Summary of promotion paper Research superviser Ilga Urtane, Dr.med.sc, professor Riga 2004
  2. 2. Euro-Qual project support the presumption that there is a need for scientificstudies about orthodontic treatment need and quality of service according to acommon European framework. Orthodontic malocclusion or dentofacialabnormality ranges from minor malalignment of the teeth to major facialdeformities. Between these extremes is a continuum of abnormalities that vary inseverity.Angles classification (1899) and Andrews (1972) six keys of occlusion have beenthe most commonly used methods for registration of malocclusion. They have,however, certain shortcomings as a method by which to categorize the variety ofocclusal pattern. For instance, they take into consideration only morphologicaldeviations, although maiocclusion may involve deviation from aestheticallylevels of different severity. To overcome the difficulty of making reliableassessments of occlusal features several methods, indices of occlusion have beendevised. An occlusal index may be used to record the severity of malocclusion,orthodontic treatment need and treatment result in a mathematical form orcategorical form.In orthodontic literature there are different indices used in different studies overtime since 60 and 70ties.In late 80ties Shaw and Brook introduced the Index of Orthodontic TreatmentNeed (IOTN). Recently Richmond and Daniels have developed The Index ofComplexity, Outcome and Need, which can be used both for the assessment oforthodontic treatment need and for the evaluation of treatment standard. EuropeanOrthodontic society has recommended IOTN and ICON for use incomparative epidemiological and clinical studies between European countries. Asmalocciusions are anomalies and not pathological conditions, they do notdemand immediate attention like diseases, and treatment is often provided for theconvenience of the patient (Ackerman, 1991). The elective nature of many
  3. 3. orthodontic treatments is also proved by Shaw et al (1989). In this longitudinalstudy he found that only severe malocclusion traits, such as, increased overjetgreater than 6 mm, traumatic deep overbite and impacted teeth, have influence ondental health. On the other hand McLain and Proffit (1985) have stated thatocclusal "..... problems cannot be defined solely in physical terms". They saythat the psychosocial consequences due to unacceptable dental esthetics may beas serious, or even more serious, than the biologic problems.In orthodontics the agreed treatment plan emerges as a result of both aprofessional and a patient centered evaluation.There are several studies which demonstrate that approximately 70% of referralsto the orthodontists were initiated by the dentist (Thilander, 1984; Gossney,1986; Shaw. 1979).In literature we can find studies investigating differences of perceivedorthodontic treatment between patients and specialists. The results are divergentMyrberg and Thilander (1973) in their study assessed orthodontic treatment needin 5459 schoolchildren and concluded that 74% were in need of treatment.However 21,2% of those who needed treatment refused it, because of treatmentduration and long travel distance to a specialist clinic. Also Espeland et al (1992)in their study with Norvegian Treatment index found that 60% of individualswho needed orthodontic treatment did not want it.However Holmes (1994) assessed orthodontic treatment need and desire fortreatment in 955 British schoolchildren. They found that patients level of concernmay be reasonably correlated to a professional assessment of treatment.In their discussion Touminen et al (1994) have pointed out a secular trend in theresults of need and demand studies, suggesting that public perception oftreatment need may be moving towards that of the orthodontic professional.Many different factors must be considered before orthodontic treatment isinitiated. At orthodontic consultations specialists assess treatment need, diagnosisand treatment possibilities of the patient. Age, treatment difficulty, long termprognosis treatment benefit and demand and other factors are also considered.This leads to a preliminary patient selection. Concurrent with growing increase in
  4. 4. the costs of orthodontic care and reduced resources, the demand for this processof priority to be built on a firm foundation is increasing.In recent years, the scientific basis for health care has gained greater attentionamong health professionals, patients, national and regional health authorities.They seek improved justification for health care practices and policies based asmuch as possible upon careful appraisals of available evidence (Goodman,1993).A consumers satisfaction with the quality of a service can be thought of as theextent of discrepancy between his or her expectations and subsequent lastingperceptions after the service is rendered (van der Heijden, 1993). Yet satisfactionappears to be a multidimensional construction that can vary significantly amongpeople and over time (Aharoney, 1993; Kane, 1997). Donabedian suggested thatmethodologies used to evaluate the quality of health care should be based on thefollowing aspects: structure (evaluation of facilities, equipment, personnel,organization and treatment cost), process (patient - provider interaction), andoutcome (measures of health status and patient outcome).Presently, no single instrument exists that can effectively measure the quality oforal health care delivery (Antezak - Bouckoms, 1995). Although the patientsperceptions of their relationship with the orthodontist (the process) and of thetreatment results (the outcomes) are important, final feelings of satisfaction aremost closely associated withthe initial expectations of treatment. Meeting patientexpectations has been found to be related to increased consumer satisfaction(Hsieh et al, 1991) orthodontic treatment effectiveness.Although the dements of satisfaction and expectation in orthodontics have beenpreviously defined (Davis, 1981) their interrelationship is not well understood.Orthodontic consumer, principally parents of young children, has been found inseveral studies to seek care for their children will benefit in terms of theirappearance (Shaw, 1975). These studies also showed that parents expectorthodontic treatment to provide social benefits.Professional assessment of effective orthodontic treatment is more based on theevaluation of the treatment result, if the occlusion is close to ideal (Andrew
  5. 5. 6 keys). There are numerous studies which evaluate and compare treatmentresults using occlusal indices (Shaw, 1991; OBrien, 1993; Richmond andAndrews, 1993; Turbill et al, 1996). Studies by Bergstrom and Hailing (1996 ab)about orthodontic treatment outcomes in three different Swedish countriesproved the role of organization and specialist resources in the effectiveness oforthodontic care.The wide variation in organization and resources internationally (Moss, 1993) aswell as nationally (Bergstrom and Hailing, 1996) obviates the necessity ofrelating results of treatment to the structure of the service in order forcomparisons to be valid.Actuality of the workIn epidemiological surveys the professionally determined need varies widely anddepends on the age, gender, type of population studies and the cut off levels forseverity of malocclusion (Holmes. 1992; Brook and Shaw, 1989; Proffit, 1998;Cooper, 2000).In many countries worldwide occlusal indices have been successfully used andgiven useful information about the severity of malocclusion and effectiveness oftreatment delivered.Our aim is to assess in detail- orthodontic treatment need in Latvian populationusing occlusal index (ICON).The question about effectiveness of orthodontic treatment carried out isimportant. There is no such full information obtained in Latvia about orthodontictreatment need, demand and effectiveness until now. This information isimportant to plan resources and to satisfy the need and demand for orthodontictreatment.The aim of the studyTo assess the need and effectiveness of orthodontic treatment in Latvian healthcare system using scientifically approved methods.
  6. 6. The tasks of the study 1)To assess the severity of malocclusion and orthodontic treatment need in population of 12-13 year old schoolchildren 2)To evaluate the subjective attitude to their own malocclusion and their desire for treatment 3)To assess the effectiveness of orthodontic treatment according to the severity of malocclusion, patient self-perception, treatment method and duration. Methods ICON The index of Complexity, Outcome and Need (ICON) has been developed (Daniels and Richmond, 2000) based on the average opinion of 97 practicing specialists orthodontists from nine countries (Richmond and Daniels, 1998). It is a single assessment method to quantify orthodontic treatment complexity outcome and need. The reliability and validity of the index is evaluated in several studies. Firestone (2002) for assessing the reliability of the method used the opinion of 15 specialists. The ICON result and experts opinion were good in 155 cases from 170. Table . ICON scoring method SCORECOMPONENT 0 1 J 4 5 WeightI. Aesthetic Score 1-10 7assessment2. Upper arch <2mm 2.1 to 5 5.1 to 9 9.1 to 13 13.1 to >17mrn 5crowding mm mm mm 17 mmUpper arch <2 mm 2.1 to 5 5.1 to 9 >9mm Impacted 5spacing mm mm tooth3. Corssbite Not present present 54. Incisor open Complete bite <1 mm 1.1 to 2 2.1 to 4 4bite mm mmIncisor overbite <l/3 lower 1/3 to 2/3 2/3 up to Fully 4 incisor covered fully covered covered covered5. Buccal segment Cusp to Any cusp Cusp to 3antero-posterior embrasure relation up cusp noly; Class I; tt to but not or III including cusp to cusp
  7. 7. Aestheticalcomponent The ICON consists of five components: The Aesthetic Component (AC), upper and lower crowding/spacing, assessment, presence of a crossbite, degree of incisor open bite /overbite, and fit of the teeth in the bucal segment in terms of the anterior posterior relationship. Each component can be measured on study casts as well as on patients. The practical application of the index is simple and takes approximately one minute for each case. The questionnaires Information about childrens own perception of their dental appearance and demand for orthodontic treatment was collected by means of a self administrated questionnaire. The answers were assessed using a Liker type scale- The number of items chosen on the scale was five. All participating schoolchildren completed the questionnaire in the school dentists office.
  8. 8. In order to compare our results with other studies, our questionnaire was basedon the previously developed analogues (Stenvik et al, 1996.; Pietila, 1996). Toevaluate the effectiveness of treatment results from the patient point of view wedeveloped a questionnaire. With the help of this self-administeredquestionnaire we gathered information about the patients own perception andattitude to the existing malocclusion before and after orthodontic treatment. Thisquestionnaire was developed taking into account the criteria suggested by Carey(1993). The patient completed the questionnaire in the waiting room at the end ofthe orthodontic treatment. The patient questionnaire was on an A4 form. Thepatient perception and attitude to the existing malocclusion was assessed using aLiker type scale.The criteria for selecting questions in the cost part of the questionnaire werebased on the relevant economic factors relating to the health care provision, asexplained in the literature review. More specifically, the questionnaire addressedthe distance traveled, the total time involved in the visit, the alternative use thistime and the occupation of the main breadwinner of the household.Material and protocolTo realize the aim of our study we set three tasks. To fulfill these tasks wedeveloped several study groups.Orthodontic treatment need and subjective demand study groupFive hundred and four schoolchildren aged 12-13 years from five rural schoolsand four urban schools were examined using the ICON index.These schools and schoolchildren were selected according to the World HealthOrganization ICS II criteria (1993). One orthodontist screened all children usingthe ICON in a dental setting in the schools. According to the second task thechildren were also invited to complete a questionnaire about treatment need andtheir appearance (Appendix 1).
  9. 9. Table 2. Distribution of schoolchildren and schools.Settings (number of Number of %schools) schoolchildrenRiga (2) 149 29,6Ventspils(l) 48 48 9,5 9,5Daugavpils (1)Saldus (1) 56 11,1Madona (1) 50 9,9Limbazi (1) 50 9,9Jelgava(!) 54 10,7Valmiera(l) 49 9,7Total: 504Assessment of effectiveness of orthodontic treatmentStudy groupsTo assess the effectiveness of treatment carried out in the Orthodontic clinic ofInstitute of Stomatology 73 dental casts pre and post treatment were examinedusing the ICON index. The patients were aiso invited to complete a questionnaireabout self-perception and attitude to the existing malocclusion (Appendix 2).According to the severity of malocclusion before treatment and to the treatmentmethod all patients were divided into two groups. In the first group we included40 patients (14 boys and 26 girls) who had mild and moderate malocciusions andwere treated with fixed systems in both arches. The mean age of patients was16,5 years ± 3,5 years. In the second group we included patients with severe andvery severe malocclusions. They were treated by means of orthodontics andorthognatic surgery. The mean age of patients in this group was 20,5 years±1,3 years.Statistical analysesThe proportions of children in different schools needing treatment, as defined byhaving an ICON score of at least 44, were compared using Pearson x2 test. ICONscores between the schools and settings were compared using one way analysis
  10. 10. Descriptive statistics, including means, standard deviation, and ranges werecalculated for the questionnaire results, treatment and ICON scores.The frequencies of different factors were analyzed using Pearson x test. Aprobability at the 5% level or less was considered statistically significant. Thedifferences in mean treatment duration according to mean self-perception wereevaluated by the analyses of variance.The statistical significance of differences betweens groups and before and aftertreatment was evaluated by standard t-test.ResultsThe severity of malocclusion and orthodontic treatment in population of 12-13aged schoolchildrenThe prevalence of malocclusion for eight schools is shown in Figure 1. Figure 1.Percentage need for orthodontic treatment in Latvia using the ICON.
  11. 11. The need for treatment, according to an ICON score of at least 44, ranged from27,5 to 58,3 percent. The differences between these percentages were statisticallysignificant (p< 0,01). There were no significant differences between urban andrural areas, with 34 percent of subjects in rural areas and 37 percent in citiesneeding treatment. Thirty two percent of boys needed treatment, compared with37 percent of girls, but this difference was not significant.The box plot (Fig. 2) shows the distribution of scores in various schools.Analysis of variance confirmed that there were no differences betweenurban/rural areas and for between boys and girls. However, it did show that therewere significant differences between schools, the multiple comparison testsindicated that the difference between Riga, with a mean of 27,5, and Daugavpils,with a mean of 48,5, was significant (< 0,01).Figure 2. Distribution of ICON scores (box plots) for the nine urban (U) andrural ® settings in Latvia. (The box shows the 25 h to 75lh percentile with the black linemean score. The wisker represents the smallest and largest outlying values. The circles andnumbers represent the outliers.)
  12. 12. Regarding treatment complexity (Table 3), the degree of difficulty did not vary significantly between schools (very difficult ranging 1,3-10,4%). Only 10 percent were considered "Difficult or very difficult". Table 3. Distribution of orthodontic treatment complexity between the urban (U) and rural(R) settings using ICON.Settings Easy Mild Moderate Difficult Very difficult Total (n)Daugavpils (U) 22,9 35,4 18,8 12,5 10,4 48Riga (x2) (U) 36,9 44,3 14,8 2,7 1,3 149Ventspils (TJ) 29,2 39,6 14,6 14,6 2,1 48Jelgava (R) 33,3 48,1 9,3 5,6 3,7 54Limbazi (R) 48,0 40,0 12,0 4,0 6,0 50Madona (R) 40,0 34,0 16,0 4,0 6,0 50Saldus (R) 37,5 39,3 14,3 7,1 1,9 56Valmiera (R) 30,6 46,9 12,2 6,1 4.1 49Total (%) 34,3 41,7 14,1 6,2 3,8 Schoolchildren self perceived orthodontic treatment need With regard to the questionnaire, the responses were compared with those individuals needing and those not needing treatment according to the ICON. Statistically significant differences occurred with respect to questions 1., 2. and 7. These were also the only questions in which the scores were correlated with the ICON score. For question 1 those dissatisfied with the arrangement of their teeth were more likely to require treatment according to the ICON; similarly for question 2 those who wanted their teeth to be straightened were more likely to have a clinical need according to the ICON. For question 7, 49 percent of those who thought they needed treatment did so; 26 percent of those who were unsure needed treatment, and 26 percent of those who said they did not need treatment were judged to need it. There were differences between boys and girls for questions 1., 2 and 7. There is a consistent: girls were more likely than boys to be dissatisfied and judge that they needed treatment. The dissatisfaction with the dental appearance was 35 percent of all schoolchildren and 67 percent wanted their teeth straightened. There were no statistically significant differences for either question 1 or 2 between urban and rural settings.
  13. 13. Effectiveness of the orthodontic treatmentA total of 73 individuals study models pre and post treatment were scoredapplying ICON. All patients were invited to fill in the questionnaire. There was a100 percents response rate for the study.Patients were divided into two groups according to the severity of malocclusionand treatment method.ICON score pre and post treatmentTable 4 shows the mean ICON scores pre and post treatment in both groups.Pretreatment score was significantly higher in the severe malocclusion group (p <0,01). The mean values after treatment were not statistically different betweentwo groups. According to the improvement grade in category "greatly andsubstantially improved" there were 85 percent of cases from moderatemalocclusion group and 87,9 percent of cases from severe malocclusion group.Table 4. Mean score of selfperceived dental appearance (standard deviation) andmean ICON score in group 1 and 2. Group 1 Group 2 PSelfperceived dental appearance 1,40(0,84) 1,36 (0,69) NS*before treatmentSelfperceived dental appearance 4,3 (0,79) 3,97 (0,95) 0,1after treatmentSelfperceived communicating 1,30(0,65) 2,58 (1,39) 0,001problems before treatmentSelfperceived communicating 1,15 (0,48) 1,21 (0,48) NSproblems after treatmentProblems with biting and chewing 1,50 (0,87) 2,18(1,18) 0,01before treatmentProblems with biting and chewing 1,30(0,61) 1,15 (0,36) NSafter treatmentICON score before treatment 63,45(18,91) 84,58(10,82) 0,001ICON score after treatment 17,18(5,98) 18,52(6,86) NS *No statistical difference between groupsThe mean treatment duration was statistically different between groups (p <0,01). Patients with moderate malocclusion were treated on an average 18,5months (± 6,7 month) but patients with severe or very severe malocclusion weretreated on an average 27,9 month (± 6,1 months).
  14. 14. Tables 5 and 6 show a relationship between the improvement of malocclusionmeasured by ICON and the mean treatment duration.Table 5. Relation ship between improvment and treatment duration in group 1.Improvement Greatly Substantialy Moderately Minimalygrade improved improved improved improved Not improved or worseMean 20,6 16,7 16,2 12,0 30,0treatementduration(months)SD 8,1 5,0 3,3 0 0* SD - standard deviation Table 6. Relation ship between improvment andtreatment duration in group 2. Improvement Greatly Substantialy Moderately Minimaly Not grade improved improved improved improved improved or worseMean 27,3 27,1 32,8 - -treatementduration(months)SD 6,2 5,2 6,7 - -* SD - standard deviationThere were no statistically significant differences between the improvementgrade and treatment duration within scope of each group.Patients self perception of malocclusion and treatment resultBefore orthodontic treatment 92 percent of all patients in both groups weredissatisfied and partly satiesfied with their dental appearance. In the moderatemalocclusion group (group 1) 90 percent of patients did not tike the aesthetics oftheir teeth but in severe malocclusion group (group 2) there were 95 percent ofsuch patients.Figures 3 and 4 show the self-perception of dental appearance in both groupsaccording to the gender of a patient.
  15. 15. Figure 3. Self-perceived dental appearance before orthodontictreatment in group 1.Figure 4. Self-perceived dental appearance beforeorthodontic treatment in group 2.After treatment 94 percent of respondents reported that they were "satisfied" or"very satisfied " with their dental appearance. AH patients in the moderatemalocclusion group (group 1) were "satisfied" or "very satisfied" with theirdental appearance after orthodontic treatment. In the severe and very severe
  16. 16. malocclusion group there was a slight difference, but it was not statisticallysignificant. After orthodontic treatment 6 percent or 2 patients in this groupreported that they are not satisfied with their dental appearance. Figures 5 and 6show the patient self-perception of their dental appearance in both groups aftertreatment according to the gender.Figure 5. Self-perceived dental appearance after orthodontic treatmentin group 1.Figure 6. Self-perceived dental appearance after orthodontic treatmentin group 2.
  17. 17. With respect to self-perception of treatment result the majority of patients, 74percent of all respondents, rated their treatment as "very successful" and 24,5percent as "successful". There was one patient in the severe malocclusion group(group 2) who was not satisfied with the treatment result. There was also astatistically significant difference in the treatment result evaluation betweengroups according to the gender. In the severe and very severe malocclusion groupfemale patient self perception of treatment result was lower than male patient -mean score 3,7 points for females and 4 points for males.Tables 7 and 8 show a relationship between patients self perceived treatmentresult and treatment duration in both groups.Table 7. Self-perception of treatment results due to treatment duration group I. Self-percpetion of treatment Satisfied More than Very satisfied result satisfiedMean treatment duration 23,9 19,0 15,9SD 8,7 6,2 4,7Table 8. Self-perception of treatment results due to treatment duration group 2.Self Dissatisfied Partly Satisfied More than Verypercpetion of satisfied satisfied satisfiedtreatmentresultMean 38,0 33,0 36,7 28,9 26,6treatmentdurationSD 0 0 6,1 5,2 7,0We revealed a tendency in the moderate malocclusion group that patient whosetreatment time was shorter were more satisfied with the treatment result.Difficulty with masticationOverall 58,9% of all respondents reported no problems with masticator functionbefore orthodontic treatment. There was a statistically significant differencebetween the two groups (p ± 0,01). In the moderate malocclusion group 17,5%reported "some difficulty" and great difficulty", but in the severe and very
  18. 18. severe malocclusion group 24,2% reported "some difficulty" and 18,2% "greatdifficulty" with chewing before treatment.After treatment 80,8% of all respondents reported no problems with biting andchewing. There was also no statistical difference between the two groups.Comparing the answers before and after treatment we observed significantimprovement in self-evaluation of masticator function in the severe and verysevere malocclusion group.MethodsThe ICON is a relatively new index and is just beginning to be used more widely.It has been shown to be a reliable and valid index (Koocher wet al, 2001;Firestone et al, 2002) for assessing orthodontic treatment need and outcome. Theaccuracy if the indexes reflect professional opinion for a diverse sample of caseswas estimated at 84 percent for decisions of treatment need and 68 percent fortreatment outcomes. The method is heavily weighted by aesthetics (Daniels andRichmond, 2000).The ICON can be used to assess the treatment need, severity of maloccfusion aswell as treatment outcome. This was the prerequisite to use this method in ourstudy.Questionnaire is a widely used method for evaluation of patients attitude to theirmalocclusion and orthodontic treatment. This method allows to standartize thecriteria and has been used in numerous other studies for subjective assessment oforthodontic treatment (Espeland, Cons, Helm).The advantage of the Liker scale, used in answers, is that it is based on a single,linear underlying continuum. This linear interval scale permits us to treat scoresintegers which may be added, subtracted and multiplied. This scale also allowsthe subjects to place themselves on an attitude continuum for each statement. Thereliability of a Liker scale tends to be good. This may be because of the greaterrange of answers permitted to respondents. Respondents tend to prefer to expressa degree of satisfaction rather than respond to "satisfied" or "not satisfied"questions.
  19. 19. The severity of malocclusion and orthodontic treatment need in population of12-13 year old schoolchildren. The mean level of treatment need of 35,3percent across all setting is similar to other studies in England and Wales(Brook and Shaw, 1989; Burden and Holmes, 1984; Office for populationCensues and Surveys, 1994). But this figure masks a considerable variationbetween schools. For example, a greater need was found in Daugavpils(58,3%) than in Riga (27,5%). This difference is not fully explained. It ispossible that those variations are related to factors not investigated in our studyand need further investigation to evaluate those reasons. There are nostatistically significant difference in treatment need between rural and urbansettings and this is similar to other studies (Tullock, 1984; Bergstrom andHailing, 1996).Regarding the severity of malocclusion, 10 percent or schoolchildren have severeor very severe malocclusion. In literature also we can find that the severity inpopulation varies from 5% to 14% depending on the method used for assessingmalocclusion and on the patients age (Ratchiller and Ingervall, 1984; Shaw etal, 1989). Our data reveal that ICON is more sensitive in showing the degree ofseverity of malocclusion and the treatment need in general as well as it betterreacts on regional variations when comparing with results in PVO ICS II project(1993).We cant underestimate the individuals concern for their own dental appearanceas it represents a decisive factor in the demand for treatment and assessment oftreatment goals (Stenvik; Shue Te Yen M).Interestingly, in our study the need for orthodontic treatment determined by theICON score is related to the individuals subjective assessments of satisfaction ofappearance and the perception of need to straightness their teeth. We found nostatistical difference between answers about subjective satisfaction with dentalappearance and self-perceived need for treatment. There findings is similar toother studies (Shaw; Helm).The need of boys and girls were not found to be different but their self-perceivedneeds were different, with girls feeling more in need of treatment than boys.Previous studies also have shown that females are more dissatisfied with the
  20. 20. appearance of their dentition than males (Shaw; Sheats) as well as femalesperceive a need for braces more often than males (Wheeler). The results showthat there are no considerable regional variations in subjective assessment ofdental appearance and selfperceived need.In previous study carried by World Health Organization ICS II in 1993subjective need for orthodontic treatment expressed 19 percent schoolchildrenaged 12-13 years. On the contrary in our study 65 percent of schoolchildrenwanted their teeth straightened. These differences in self assessment can havehappened because of increasing role of facial appearance in the society andavailability new methods of treatment. It is state that improving socials economiclevel lead to increasing self perceived need for improving individuals estheticappearance, including teeth (Proffit WR, 1998).Evaluation of Efficiency of Orthodontic TreatmentIn evaluating the efficiency of orthodontic treatment, clinically the most oftenused method is comparison of occlusion models prior and after treatment, thusdetermining the introduced changes during the treatment process. However, thismethod reviews only part of the whole orthodontic treatment process.The study groups are sufficiently presentable within the scope of one clinic. Ourstudy groups in some respect do not represent the whole population, but it ispresentable from the point of view of the occlusion anomalies treated in theStomatology Institute and Latvian regional representation. This could beregarded as classical population, to which orthodontic treatment is provided on aregular basis in the Stomatology Institute. In the first group the largest group ofpatients is schoolchildren, which is also evidenced by the average age of 16,4.As it was expected the mean age of patients among the groups was varied, sinceto the patients included in the second group with heavy and very heavy occlusionanomalies orthodontic and orthognatic therapy is performed after the end ofgrowing. The mean age of this group - 20,5 years - evidences that young peopleare readier to accept more cardinal treatment methods. In some respects it couldbe related to the fact that they link the rise of their socio-psychological status in
  21. 21. the future life with correction of occlusion anomalies. Although, in the firstgroup the mean age was expected to be higher taking into account the increasingdesire to receive orthodontic treatment of grown-up patients, the results of thisresearch do not prove that. It could be partly explained by expansion of theprivate sector. Perk (1997) concludes that a large part of the grown-up patientsare more treated in private practices than are referred to university clinics. Theother factor could be a speculative opinion of the society, that orthodonticregulation is possible and could be performed in adolescence and that applianceis aesthetically noticeable and could cause discomfort in relations with othergrown-ups.In respect to the gender of patients women were proportionally more representedin both groups. It could mean that occlusion anomalies are a greater concern togirls than boys and they want to correct them. Thus, the tendency complies withother published research (Shaw, 1981; Sheats, 1998; Wheeler, 1994). It isinteresting that an even greater difference between gender is found in the secondgroup, where anomalies are heavy or very heavy. However, either Barber et al(1992) or Beily et al (2001) in their research on division of orthodontic patientsand their wishes hold a similar opinion. Hence, we may conclude that womenmore frequently wish to receive treatment and more often agree to the offeredtherapeutic possibilities.The mean initial ICON indicator is 63 and respectively 84 points, which showthat most patients have severe or very severe anomalies. These indicators complywith the data received in other research on orthodontic treatment in universityclinics (Espeland and Stenvik, 1991; Birkeland et al, 1999, Firesotne, 1999). Inour research 93,1% of the patients fell into the category of necessity fortreatment and only 6,8% or in respect to 5 patients the value of ICON was lessthan 43. All these patients were in the first group, where the pre-treatmentseverity level was moderate. It could be explained by the fact that the decision onorthodontic treatment is a joint combination of wishes and needs of the patientsand/or their parents and specialists (Shaw et al, 1981).
  22. 22. However, the treatment result according to ICON in both groups is notstatistically different. It means that notwithstanding the severity of the occlusionanomalies and therapy method, the obtained results have a high standard, andfrom the point of view of treatment result it can be considered that the therapy iseffective. It relates to the data obtained in Richmond and Andrew (1993) researchon evaluation of the results of orthodontic treatment performed by specialists inNorway.Similarly AL Yami investigated the result of orthodontic treatment in NimmingenUniversity clinic in the Netherlands, and 91% of the evaluated results wasincluded in the section of "considerable improvement" or "improvement". Thelatest literature show increasing number of data on wishes of patients,treatment results and patient satisfaction interaction in respect to orthodontictreatment, however, there is no unequivocal opinion or definite indicators {Vig,1999; Bos et al, 2003). In our research the satisfaction of patients and wish fororthodontic treatment was determined by their attitude towards the appearance oftheir teeth before and after treatment, the evaluation of the orthodontic treatmentresult, as well as evaluation of the occlusion function before and after therapy.The research is retrospective, since the patients filled in the questionnaire aftercompletion of the treatment; such an approach can also be found in otherliterature data, when past and present evaluation questions are combined in oneresearch to determine psychosocial aspects of occlusion anomalies. In subjectiveevaluation of the self-perceived dental appearance prior to treatment there was nostatistically considerable difference among groups and gender, which meansthat all patients mostly wish to improve their looks. Very often individuals, whoare not satisfied with their looks, mention the bad likeness of teeth as thereason for that. Therefore, most people consider orthodontic treatment asdentofacial improvement (Albino, 2000; Giddon, 1984; Lew, 1993). The obtainedresults on self-evaluation of patients after treatment are not that homogenous asthe evaluation prior to the therapy and as was expected.Looking deeper into the division of gender, we concluded that particularlywomen were not satisfied with the result reached by therapy and the appearance
  23. 23. og their teeth (though, these results are not statistically credible). It could beexplained by the fact that women are more concerned with improvement of theirlooks. Similarly Philips (1997) in his research on factors, which make individualsvisit an orthodontic consultation, concludes that men link improvement of theirlooks and functions with social welfare changes, while women are moreinterested in looks as such. The fact that most patients in both groups weresatisfied with the appearance of their teeth and the result of therapy conformswith other carried out research (Kiyak, 1986; Busby, 2002). The observeddissatisfaction with the appearance of teeth after therapy could be explained byan understanding that the larger the dissatisfaction with the look of the face, thelarger and the better treatment the patient wishes to receive (Shaw, 1981;Cunnigham, 2000). The obtained data also comply with the point of view thatthere are differences among the sexes in perception of treatment results(Goosney, 1986). It is possible that in this case the wishes of patients were notfully found out or the obtained result did not comply with the expectations. Suchan opinion is expressed by Kiyak (1986; 1998) and Philips (1997) in theirresearch on subjective self-evaluation of patients.Hence, we must agree with the conclusions of Jacobsen (1984) thatnotwithstanding the numbers of the patients satisfied with the result of thetreatment, it is important to pay attention to those patients, who have expresseddissatisfaction with the achieved result. He decides that not always an ideal resultwill be reached, but in cases when the aesthetic changes will not be that explicitor will be limited, it is vital to inform the patient about that and not let the patientthink otherwise.Considering the above mentioned indicators: ICON result before and aftertreatment, self-evaluation of the likeness of the teeth of patients, division amongpathology groups of self-evaluation of communication and functional problemsprior and after therapy, the obtained results show that the planned orthodontictherapy result is reached, which is evidenced by the statistical difference in thebeginning of treatment and non-presence of statistical difference at the end of thetreatment either in the objective ICON or subjective self-evaluation.
  24. 24. The results of our research conform to the data of Bergstrom et al (1998) on theaverage length of treatment in a specialist clinic. Jarvinen (2002) analyzingefficiency of orthodontic treatment in Finland notes that the average length oftreatment is 2,8 years. Although there are differences among groups in respect tothe length of treatment, the average indicators comply with the results obtainedin other research (Richmond and Andrews, 1993; Birkerland, 1997; Fox andChadwik, 1994). Interesting that when comparing the objectively obtained resultson the level of occlusion improvements, the results show that the patients in thefirst group, who have had a longer period of treatment, have greaterimprovement. This relationship could be explained by that the initial occlusionanomaly of these patients was larger {Richmond, 1993). No relationship wasobserved within the second group, which could indicate that the initial anomalyof all patients was similarly severe.In order to better evaluate the satisfaction of patients with orthodontic treatmentwe determined the judgment about their self-evaluation and results of treatmentdepending on the length of treatment. The results of our research showed that inthe first group the self-evaluation of patients is higher, if the length of treatmenthas been shorter. Seemingly in replying to the question about self-evaluation ofthe appearance of teeth after treatment in the questionnaire the patientspsychologically relate it to the length of wearing the orthodontic appliance.While in the second group where the occlusion anomalies were very heavy, nosuch relationship was established. It shows that the patients understand that theanomaly is very heavy and requires lengthy treatment and therefore the timefactor has no relevance.SummaryDistribution of occlusion anomalies and determination of necessity oforthodontic treatment are important factors in planning of orthodontic treatment.The information on attitude of patients towards their occlusion anomalies hasincreasing importance. We in our research determined the necessity oforthodontic treatment in the population of 12-13 year old schoolchildren and
  25. 25. found out the self-evaluation of school children, because it is difficult to createand organize serious care system without good evaluation of the necessity oforthodontic treatment and wishes or demand. The indicator of necessity fororthodontic treatment obtained in our research complies to the results ofepidemiological research performed in other European countries. However, weestablished considerable regional differences between the schoolchildren in Rigaand Daugavpils. It is difficult to explain these differences, because seeminglythere are some additional factors for investigation of which further detailedresearch is required. For determining the necessity for orthodontic treatment weused the occlusion index ICON, because this method is widely used and isrecognized as an objective means to determine distribution of occlusionanomalies and the severity level in epidemiological research. ICON is arelatively new index, but the results of our research and literature evidence thatwith the help of it, it is possible to determine objectively the necessity fororthodontic treatment and the severity level of occlusion anomalies in thepopulation, and it is sufficiently sensitive to show differences in necessity fortreatment within the scope of population.Since orthodontic treatment has a certain factor of choice in comparison withother fields of medical care, determination of the attitude of the patient towardsthe appearance of the teeth and wish for treatment is vital. In our researchindividual self-evaluation of appearance of the teeth and wish for orthodontictreatment statistically significant correlates with the clinically determinednecessity discovered by ICON.It is essential to evaluate the changes of individual wishes and self-evaluationwithin a longer period of time. Within ten years the subjective self-evaluation ofindividuals and demand for orthodontic treatment in Latvia have considerablyaltered. The desire to correct teeth has grown several times. Seemingly theimportance of looks has grown in the socio-psychological field and new moreeffective treatment methods are available, since in any relationship uponimprovement of general socio-economic indicators, the wish to improve thelooks grows as well.
  26. 26. Clinical audit or evaluation of orthodontic treatment efficiency is a systematicmethod to assess whether the determined treatment results are reached and tointroduce further enhancement. In the Stomatology Institute Orthodontic Clinicorthodontic treatment is provided to patients with mild and severe occlusionanomalies. The patients, who visit the orthodontic specialists, are from the wholecountry.Notwithstanding the objective level of occlusion anomalies, they look for highquality assistance. As a result of treatment the objective evaluation, applyingICON, depending on the severity of occlusion anomalies evidence that thetreatment provided in the clinic is of good quality and the set treatment aims arereached. This is shown also by the first questionnaire of patients, which is asubjective criterion for determining efficiency of the treatment. The objectiveICON indicator complies with the subjective opinion on the necessity fororthodontic treatment and the result of the treatment, and it illustrates thatorthodontic treatment is effective notwithstanding the severity level of occlusionanomalies. Also for the first time one of the factors for determining the quality oflife of patients - satisfaction with therapy, including cosmetic effect, mutualcommunication, presence of functional disturbances - has been evaluated. Sincehealth of a mouth is part of general health and is related to the quality of life ofthe patient, contemporary understanding of the level of influence of orthodontictreatment on the quality of life is vital. For the performed orthodontic treatmentto be efficient it is important to objectively inform the patient on the possibilitiesof orthodontic treatment as well as to find out the wishes of the patient, sincecreation of such an occlusion, which would satisfy the patient, functions best andis stable in a longer period of time, is the basis of qualitative orthodontictreatment.
  27. 27. Conclusions1.The severity of malocclusion (severe malocclusion l,3%-10,4%) and theorthodontic treatment need (35,3%) among 12-13 year old schoolchildren inthe population of Latvia is similar to the data of other developed countries.2.The subjective evaluation of the school children of the appearance of teethand wish for orthodontic treatment is closely and statistically significantrelated with the objectively determined necessity for orthodontic treatment.3.The objective clinical evaluation of treatment effective assessed with ICON isof high standard apart from the severity of malocclussion.4.The patients subjective self evaluation depends on the gender, severity ofmalocclusion and treatment duration.5.Assessment of effectiveness of treatment is more related to the patientssubjective self evaluation. It does not depend on the severity of malocclusion,treatment method and duration.Publications:1.A. Liepa, I. Urtane, D. Cakame / Epidemiology of Dentofacial Anomalies inLatvia/ Stomatologija, 2000/3, 14.-16.., ISSN 1392-8589.2.A. Liepa, I. Urtane, D. Osleja. "Occlusal indices and their practical use","Stomatologija", 2000/3, 26-28., ISSN 1392-8589.3.A. Liepa, I. Urtane / Dentofacialo anomaliju subjektlvais un objektlvaisnovertejums / LMA/ RSU Zinatniskie raksti 2001/2 254.-256., ISBN 9984-550-53.4.A. Liepa, I. Urtane / Use of ICON in treatment outcome assessment of severemalocclusions / Stomatologija, Lietuva, 2002/1, 33.-35., ISSN 1392-8589.5.A. Liepa, I. Urtane, S. Richmond, F. Dunstan / Orthodontic treatment need inLatvia / European Journal of Orthodontics 25 (2003), 279 - 284. 1. A. Liepa, I. Urtane / Orthodontic Treatment Standard in Specialist and Non- specialist practices in Latvia / Stomatologija, Lietuva, 2003/2, 48-51, ISSN 1392- 8589.
  28. 28. 2. Appendix 1.Name, Surname____________________________________Age_____________________________________1. Are you satisfied with the arrangement of you teeth? Very satisfied o Satisfied a I do not care a Dissatisfied n Very dissatisfied a2. Do you want your teeth straigthened? Yes, definitely n Yes, probably n No, probably no a No, definitely not a3. Do you consider well aligned teeth important for overall facial appearance? Very important a Rather important □ Not important a Not important at all □4. How satisfied are you with your dental health? Very satisfied n Satisfied □ Dissatisfied D I do not care o T do not know a
  29. 29. 5. How often do you brush your teeth? Several times a day □ Once a day a At least once a week a Less than oncew a week d6. Have you ever worn an orthodontic appliance? Yes D No n T do not know □• If -yes" who suggested treatment Myself a My parents n Dentist n Friend a I do not know a7. Have you ever thought you are in need of treatment? Yes a N o □ T do not know a* If Myes" please give the main reason for your concern Appearance of teeth is unsatisfactory □ Function of the dentition is unsatisfactory a Cleaning of teeth is difficult a Some other reason I do not know n
  30. 30. Appendix 2QuetionnaireName SurnameAge Gender M F 1 21. Are you satissfied with your dental appearance now?dissatisfied satisfied very satisfied 1 2 3 4 52. Oo you have any difficulty of chewing and biting now?no difficulty very great difficulty 1 2 3 4 53. How good was your cooperation during treatment. very bad average excellent 5 1 2 3 44. Are you satisfied with the treatment result?very dissatisfied dissatisfied satisfied very satisfied (< 30%) (31-60%) (61-80%) (> 81%) 12 3 45. Were you satisfied with your dental appearance before treatment?dissatisfied satisfied very satisfied 1 2 3 4 56. Have you had any difficulty with biting or shewing?no difficulty very great difficulty 1 2 3 4 57. How do you get to the ctinic? by foot by car bay train by bus taxi 1 2 3 4 5a. How long is the distance to the clinic? > 1 km 1-5 km 6-10 km < 10 km 1 2 3 49. How much time do you spend on your way? > 5 min 6-15 min 16-30 min < 30 min 1 2 3 410. Your occupation?11. Do you need specially take time off to, visit a specialist? YfiS No 1 2
  31. 31. 12. If yes, please state the reasonday off leasure to cut school other:......................................................from work activities 1 2 3 413. The occupation of your main breadwinner.14. How much time including waitting do you spend in the clinic?> 15 min 15-30 min 30-45 min < 45 min 1 2 3 415. Had you any problems in communicating with other people before treatment? no problem average very great problem 1 2 3 4 516. Do you have any problems in communicaty with other people now? no average very great problem 1 2 3 4 5

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