Needs, demands and appropriateness of referral to

orthodontic treatment in the North West Armed Forces

Hospital in Tabuk, Saudi Arabia

Abdulaziz Al-Rasheed* BDS, Wael Sabbah**BDS, DDPH, MSc,
Harikrishnan Pandurangan***BDS, MDS, FRCP
*Dentist, North West Armed Forces Hospital, Tabuk, KSA,
**Research Fellow, University College London, UK
*** Madras, India

This study aimed at assessing normative needs for orthodontic treatment, other dental problems, socioeconomic condition and attitude toward dentistry among a sample of patients who were referred for orthodontic treatment in the Northwest Armed Forces Hospital (NWAFH) in Tabuk, Saudi Arabia.  A convenient sample of 320 patients who were referred for orthodontic treatment was selected to participate in the study.  Patients were asked to complete a questionnaire on perception of their oral health status, demands for orthodontic treatment, other oral treatment needs, attitude toward dentistry and socioeconomic factors.  Patients were examined by a consultant orthodontist to assess their normative orthodontic needs using the Index for Orthodontic Treatment Needs (IOTN).  Other dental needs were also assessed.  Percentage of females referred for orthodontic treatment was slightly higher than males (60%). Socioeconomic factors did not seem to influence demands for the service.  Only 34% of the sample had IOTN score of 3 or more (moderate to very great needs), 52% had caries in at least one tooth, 48% had bleeding on probing, 22.3% had calculus, and 5.6% had pocket 4 mm or more. The results of the study indicated that while demands for orthodontic treatment seemed to be exaggerated, needs for other dental treatments were underestimated.  The results implied that expensive and specialized dental services were highly promoted in a community that lacks appropriate access to primary dental care.  The results necessitate the development and implementation of proper guidelines for referral for orthodontic treatment.  There is also a need to increase the emphasis on highly needed primary dental care.

Increasing demands for efficiency in the delivery of dental services necessitate continuous assessment of quality of care and monitoring of the appropriateness of referrals for specialized dental care.  Orthodontic treatment is one of the complicated, long-term treatment and costliest dental specialties, which requires the work of highly trained specialists.  However, studies have shown that demands for this service are not always consistent with the patient's actual needs.^1,2  While some patients with near normal occlusion might express orthodontic concern others with great need may not express concern.³  Even when patients were referred by a dentists, significant number of the referrals were inappropriate.⁴  Research on orthodontic treatment needs also suggested that perception of orthodontic treatment needs might be influenced by factors such as socioeconomic status, availability and affordability of the service.^5,6

Similar phenomena were observed among patients demanding orthodontic treatment in the Northwest Armed Forces Hospital (NWAFH) in Tabuk, Saudi Arabia.  Although all patients seen by the orthodontist consultant were referred by general practitioner (GP) dentists, demands for orthodontic treatment were not always justified by normative needs.  It was also observed that many patients who showed concerns about their occlusion and requested orthodontic treatment had more immediate dental treatment needs for dental caries and periodontal diseases but they were either unaware of these needs or perceived them unimportant.  The impact of this phenomenon would be an increase in workload on an already busy specialist.  It might also influence policy makers to shift the emphasis from greatly needed primary and preventive services toward possibly exaggerated, expensive and specialized treatment.  This will lead to an increase in the cost of dental services without improving the oral health status of the population.  Therefore, it was necessary to examine the normative orthodontic and other dental treatment needs among those who demanded orthodontic treatment at the NWAFH.  It was also important to examine socioeconomic and culture factors that might influence patients' decision to seek orthodontic treatment.

A questionnaire was developed which contained questions pertaining to patients' socioeconomic status, education, attitude toward dentistry, perception of oral health status and needs for orthodontic treatment (Appendix 1).  A convenient sample of 320 patients who demanded orthodontic treatment and who were referred to orthodontic consultant in the NWAFH participated in the study.  A consultant orthodontist and a GP dentist, who were trained on using the Dental Health Component (DHC) of the Index for Orthodontic Treatment Needs (IOTN), conducted the clinical examination.⁷  All participants included in the sample were examined by the orthodontist to assess orthodontic treatment needs using the DHC of the IOTN.  Patients with scores 3-5 (moderate to very great need) were included.  Subjects with untreated caries were considered inappropriate referrals. Participants were also examined to check the presence of untreated caries, missing teeth and periodontal condition using the CPITN Index.  Participants and/or their guardians were requested to complete the questionnaire.  Ten percent of the patients were re-examined to check for reliability.

Data obtained from the clinical examination and the questionnaire were entered into a computer database and the SPSS program was used to analyze the data.

Out of the 320 patients who participated in the study, 59.7% were females.  The age ranged from 7 to 46 years, mean age was 17.8.  Around 90% of the participants were military staff or their dependents.  Approximately 62% reported that their total family income was less than 7,000 Saudi Riyals per month.

In a group of questions pertaining to needs for dental treatment 98% perceived the need for orthodontic treatment, while only 30% thought they needed filling, 13% extraction, 47.6% oral hygiene treatment, 6.7% periodontal treatment, and 15% prosthodontic appliance.

Approximately 31% perceived their teeth appearance and alignment to be ugly, 46% perceived them acceptable and 23% thought their teeth alignment looked good.  At the same time, 66% thought they had no cavities in their teeth.  Around 82% said they brushed their teeth regularly and 37% said their gums bled on brushing.

Approximately 34% said they visited dentist regularly for check up, the rest visited dentist for emergencies only.  Thirty six percent believed that dental problems may have an impact on occlusion.

Reliability in clinical examination was high (kappa = 0.9).  When patients were clinically examined by a consultant orthodontist, using the IOTN, it was found that 66.2% of the patients had no need or little needs (Table 1).

When examination was conducted to assess other dental needs, it was found that 52.5% had dental caries in at least one tooth.  The maximum number of decayed teeth was 16 and the mean was 1.43.  Also, 44.4% of the patients had at least one missed tooth, maximum number of missing teeth was 8, and mean was 0.92.   The percentages of patients with needs for different dental problems are shown in Table 2.

When score 3 or more of the IOTN was used as an indicator for needs for orthodontic treatment, it was found that 33.9% of the patients referred for orthodontic treatment actually needed the treatment.  A simple calculation to exclude patients who had untreated dental caries in their teeth from those who had IOTN score of 3 or more revealed that only 15% of the patients were appropriately referred for orthodontic treatment.

Table 3 exhibits a comparison between patients' perception and demand for dental care and their normative needs.

Demands for orthodontic treatment were not statistically associated with gender nor with socioeconomic status indicated by income (Table 4).   Neither the level of education of parents nor that of patients was associated with demand for orthodontic treatment.

The correlation between demand for orthodontic treatment and actual need (IOTN score 3-5) was insignificant and very low (Correlation value: 0.110).

The findings of this study implied that demand for orthodontic treatment was exaggerated in the NWAFH community.  The results also implied the lack of proper standards for referral for orthodontic treatment which GP dentists could use to identify patients who needed orthodontic treatment.

While other studies considered patients with IOTN score 4 and 5 to have normative needs for orthodontic treatment,^4,6 in this study we used score 3 and above as indicators for normative needs.  However, there was an apparent inconsistency between demands for orthodontic treatment and normative needs in this study when compared to those reported in other studies.^4,8-11   At the same time, a very high proportion of the referred patients had needs for other dental treatment compared to what similar studies reported.⁴

While socioeconomic factors seemed to negatively influence patients' demands for orthodontic treatment,⁶ they did not seem to have effect on demands for orthodontic treatment in this study.  This could be explained by the fact that orthodontic treatment is free of charge at NWAFH.  Similar to what was reported in other Saudi studies, gender was not a significant factor influencing demand.^12,13

The results also indicated that the percentage of patients who were appropriately referred to the orthodontist was very low compared to other studies.⁴

Contrary to exaggerated demands for orthodontic, there was an apparent underestimation of actual needs for other dental treatment despite their effect on occlusion as indicated by other studies.¹⁴ Similar phenomenon was observed in other Saudi studies, which implied underestimation of greatly needed primary dental services and emphasis on specialized treatment.^15,16

It is true that there could be a psychological impact on orthodontic patients, even those with very minor malocclusion problem.  However, the dilemma is whether dealing with this minor orthodontic problem could be afforded in a publicly funded system that has to deal with bigger and more serious dental problems which also have their psychological consequences on patients?

While there were great demands for orthodontic treatment in the community served by NWAFH, these demands were not justified by internationally recognized standards for the diagnosis of malocclusion.  At the same time, there were greater needs in the community for primary dental services.  ^17,18,19

Address reprint request to:

Dr. Abdulaziz Al-Rasheed
Prince Abdulrahman Institute
for Advanced Dental Studies
P.O. Box 86516, Riyadh 11632, KSA

Questionnaire: Needs and demands for orthodontic treatment

Date:                                      Patient's code:

Who will fill the questionnaire:

(a) participant  (b) parent/ guardian

Table 1. Patients with actual needs for orthodontic treatment according to the "Index for Orthodontic Treatment Needs"

Table 2. Patients and clinically detected dental  condition other than orthodontic needs

Table 3. Comparison between patients’ perceptions and demands for care and their actual needs

Table 4. Distribution of patients who demanded orthodontic treatment by gender and income