The British Orthodontic Society Clinical Effectiveness Bulletin No.33 November 2014 Clinical Governance Directorate of the British Orthodontic Society

Director’s Remarks Moving House!

lthough this is the autumn edition of the 1st Prize Clinical Effectiveness Bulletin, I think there An audit of compliance in Orthodontics with has been something of a spring clean within Department of Health 2007 “Smokefree and A Smiling” guidance. the editorial ranks. This edition has been jointly produced by Kate House, the outgoing editor, and A.McMullin and S. Caldwell (University Dental Jadbinder Seehra, our new incoming editor. The Hospital Manchester). team have worked hard to produce an excellent Bulletin with an interesting range of articles. There 2nd Prize are some familiar themes again, patient satisfaction Use of the PAR index to assess outcomes of and multidisciplinary care, but some more varied orthognathic surgery in cleft lip and palate patients. projects looking at the periodontal health of our C. Rolland (VT dentist), C. Chambers (Bristol patients and their dietary habits, reflecting the wider Dental Hospital) and S. Deacon (Frenchay Hospital scope of our practice. and Bristol Dental Hospital).

Knowing that audit is strong within our specialty, 3rd Prize I was interested to read that the Healthcare Quality Orthodontic treatment and orthognathic surgery – Improvement Partnership (HQIP), the organisation do we predict the length of treatment accurately? tasked with promoting quality in healthcare, in C. Dunbar, G. McIntyre (Dundee Dental Hospital) particular increasing the impact that clinical audit and S. Laverick (Ninewells Hospital, Dundee). has on healthcare quality in England and Wales, recently promoted its second ‘Audit Awareness Many congratulations to all the winning authors. I Week’. This initiative is aimed at encouraging know it is a difficult task selecting winners with the engagement of staff at all levels in clinical audit number of high quality reports that are submitted within the workplace. Although this is aimed and published. I would like to thank all the authors principally at the medical field, it is an idea that for continuing to support this publication and the we could embrace within our specialty. I think we editorial board and referees for all their hard work in are ahead of our colleagues in this area and I am its production. pleased to see articles both from practitioners based in primary and secondary care. Within the Society I’ll finish by wishing Jadbinder every success in his the Audit committee is always thinking of ways to term as Editor and thanking Kate for all her hard increase audit’s relevance and impact. We would work over the past three years. I know that Kate has welcome ideas from members of how this could be left the Bulletin in safe hands. enhanced. Nikki Atack The BOS Clinical Audit Prizes were announced at Director, Clinical Governance the BOC in Edinburgh. The winners were chosen from the last two issues of the CEB and were awarded to: Editor’s Cut This is my first editorial as the new Editor of the BOS Clinical What does the future hold for the Bulletin? First and foremost I hope Effectiveness Bulletin. I would like to begin by thanking my very much to continue the success of this publication and continue predecessor, Kate House, for her tremendous hard work and effort. I the great work of my predecessors. I am aware of the responsibility am sure we would all agree under Kate’s stewardship the Bulletin has that comes with this role and I hope that I do not disappoint. I will be gone from strength to strength resulting in a high quality publication exploring options to further improve the submission process, overall reflecting the excellent clinical standards practised by orthodontic format and content of the Bulletin. If any member of the Society has clinicians within the United Kingdom. On a personal note, I would any thoughts and ideas, please feel free to contact me. also like to thank Kate for showing me the ropes and ensuring a BOS Clinical Effectiveness Bulletin Editorial Board smooth handover and transition. Celtic Regions I would also like to thank both Gavin Mack (South-East) and Amreen Liz Turbill ([email protected]) Ahmad (Northern) for their hard work and contribution to the success of the Bulletin. Both Gavin and Amreen, who will be leaving their Northern England positions on the editorial board, have excelled within their roles Amreen Ahmad ([email protected]) as regional sub-editors. New sub-editors for these regions will be South West and Midlands appointed in due course. I look forward to working with the existing Christian Day ([email protected]) and new editorial board members who I am sure will further enhance South East the reputation of the Bulletin. Gavin Mack ([email protected]) The success of the Bulletin is also dependent on the numerous Post- TGG representative CCST trainees across the country who undertake peer-review of Rachel Stephens ([email protected]) articles. I have found these reviews to be conducted in a careful and diligent manner and I would like to thank you all for your continued Ann Wright ([email protected]) support and excellent reviews!! This is greatly appreciated. Lastly, Jadbinder Seehra the Bulletin would not be in circulation without the numerous high Editor BOS Clinical Effectiveness Bulletin quality articles submitted for publication by members of our Society. The effort made by clinicians to report standards of clinical practice Department of Orthodontics and improve clinical effectiveness is impressive. I would strongly Kings College Hospital NHS Foundation Trust encourage all members of the orthodontic team in both primary and Denmark Hill, London secondary care to consider submitting their articles to the Bulletin. [email protected] In this issue…. 1. An audit of functional appliance treatment. C. Dunbar, 10. Documentation of the Basic Periodontal Examination scores as K. Mouton-Manhem, C. Harper. Royal Berkshire Hospital, part of the orthodontic examination for new patients: Reading A two-cycle audit. A. Hindocha , N. Patel, J. Turner, S. Visram. Birmingham Dental Hospital 2. New patient satisfaction. S. Nandhra, S. Power, E. Thickett. Royal Bournemouth Hospital 11. An audit on patient experience following orthognathic surgery. M.W Tang and A. Dibiase. William Harvey Hospital, Ashford, Kent 3. Patient satisfaction with Croydon MDT dento-alveolar clinics. L. Khamashta-Ledezma, Z. Kordi, J. Radecki, L. Davenport- 12. A regional audit of orthognathic service provision and Jones, M. Chia. Croydon University Hospital treatment duration. A.Tsichlaki1, S. Ward2. University Dental Hospital Manchester1, Royal Blackburn Hospital2 4. Retainers - What retainers? Patients understanding of orthodontic retention: A multicenter audit. J. Flanagan, 13. Audit of patient dietary habits. S. L. Stephens, R.M. Stephens, S. Kotecha, J. Panesar. Birmingham Dental Hospital S.J. Cunningham and F.S. Ryan. Eastman Dental Hospital UCLH Foundation Trust and UCL Eastman Dental Institute 5. An audit to assess the number of inappropriate referrals to a primary care specialist orthodontic practice. P. Raval. Peace 14. Clinical audit of patient oral hygiene measures. R.M. Stephens, Children’s Centre, Watford S.L. Stephens, S.J. Cunningham, F.S. Ryan. Eastman Dental Hospital UCLH Foundation Trust and UCL Eastman Dental 6. Occlusal outcomes for patients undergoing orthognathic Institute surgery in Devon and Cornwall. M.Moore, K. Drage, A. Jerreat, K. Postlethwaite, R. Robinson, A. Smith, N. Wenger. 15. Re-Audit of Orthodontic Model Boxes. F. Ahmed, H. Mazey. South West Regional Orthodontic Audit Group (Southern University Dental Hospital Manchester Section) 16. An audit of instrument decontamination standards and barcode 7. Orthognathic surgery precision - A retrospective audit of sticker usage in a London teaching hospital orthodontic planned and actual movements during maxillary surgery. department. L. Tabrett, H. Ling, P. Acharya. Eastman Dental 1 2 2 1 H. Barry , P. Shah , H. Popat and A. Cronin . University Hospital, London Dental Hospital, Cardiff & Vale University Health Board1 and School of Dentistry, Cardiff University2 17. A re-audit of the use of fluoride mouthwash in orthodontic patients. M. Storey, L. Mitchell. St Luke’s Hospital, Bradford 8. Orthodontic mini-screw effectiveness in Leeds. S.K. Barber, D.O. Morris. Leeds Dental Institute, Leeds, UK 18. A General Practice Based Audit of Orthodontic Extraction Letters. J. McGarry. McGarry’s Dental Practice, Lisnaskea, 9. A regional audit to assess the surgical re-exposure rates of Co.Fermanagh, N.Ireland ectopic palatal maxillary canines. A. Gill1, R. Valiji Bharmal1, T. McSwiney1, M. Palarajah 2, B. Bagdadi3, C. Campbell1. John 19. An audit of patient satisfaction among lingual orthodontic Radcliffe Hospital, Oxford1, Heatherwood and Wexham Hospital, patients. R. Paul Cheruvathur, H. Patel. The Liverpool Brace Slough2 and Stoke Mandeville Hospital, Buckinghamshire3 Place, Liverpool 2 1 AN AUDIT OF FUNCTIONAL APPLIANCE TREATMENT C. Dunbar, K.Mouton-Manhem, C. Harper. Royal Berkshire Hospital, Reading INTRODUCTION Overbite. Functional appliances are frequently used in the United Centreline. Kingdom for treatment of Class II malocclusions1,2. A successful outcome is strongly dependant on patient METHODS compliance, appropriate case selection and subsequent timing This was a retrospective audit completed at one district general of treatment2. If a positive treatment outcome is achieved there hospital. One hundred consecutive patients treated with a can be a fundamental effect on a patients self perception and functional appliance were identified from the laboratory confidence3. database. Patients were treated over a four-year time period from January 2007 to January 2011. Data was collected from The purpose of this audit was to investigate the outcome of the hospital notes and entered onto a proforma. The following treatment using functional appliances at the Royal Berkshire data was collected: Hospital Orthodontic Department. Previous audits completed 1. Type of functional appliance. at Worcester Hospital, St George’s Hospital and Glasgow 2. Incremental or single advancement. Dental Hospital have shown successful treatment outcome with 3. Age of patient at the start of treatment. functional appliances ranging from 58% to 77%4-6. 4. Gender. 5. Overjet at the start of treatment. Within the hospital department two types of functional 6. Overjet six months into functional appliance treatment. appliances are used, twin block and medium opening activator 7. Overjet at the completion of functional appliance appliances. Clinicians vary between a preference for one treatment. advancement or incremental advancement of the functional 8. Reason for non-compliance. appliance. For maximum advancement the functional bite is 9. Length of treatment. taken at an edge-to-edge incisor relationship. For incremental 10. Occlusal parameters recorded pre- and post-functional advancement a functional bite is taken with 6mm advancement appliance treatment. and a further appliance made once the first has been successful. A randomised controlled study by Banks et al. 2004 has RESULTS found there is no advantage of 2mm advancements with an There were 100 patients included in this audit with a mean age advancement screw compared to a single advancement7. The of 12 years 6 months. Of these 61 were male and 39 female. aim of this audit was to assess the success of treatment with The mean start overjet was 10.8mm. twin block and medium opening activator appliances and with different methods of activation. Treatment success The overall success of treatment with the overjet reduced to a AIMS Class I incisor relationship was 71% of patients in an average The aims of this audit were: treatment period of 11.8 months. In those patients whose 1. To assess the success of functional appliance treatment and treatment was not successful, according to the audit standard, length of active treatment with: the average treatment period was 13.5 months. a.Different types of functional appliances used within the department. b.Incremental compared to a single advancement of the functional appliance. 2. To evaluate the length of treatment in non-compliant Successful patients. (71%) 3. To assess the standard of recording of occlusal parameters pre- and post-functional appliance treatment. Unsuccessful GOLD STANDARDS (29%) 1. Treatment success - 100% of functional appliance treatment should reduce the overjet to a Class I incisor relationship (2-4mm). This standard was chosen as it had been used in previous audits at Worcester and Glasgow Hospitals4,6. Figure 1 – Overall treatment success to a Class I incisor relationship. 2. Non-compliance - At least a 10% reduction in the overjet should be seen within six months. If the overjet has not Table 1 shows the reasons for the 29% whose treatment was reduced by 10% in 6 months the patient will be classed not successful. as non-compliant for the purpose of this audit. This was the standard used in the O’Brien et al. 2003 study when Reason for unsuccessful treatment % of cases assessing the effectiveness of early treatment2. Poor compliance 14 3. Record keeping - All patients should have the following Did not respond to treatment 6 occlusal parameters recorded pre- and post-treatment: Did not return to department 5 Overjet. Overjet or reverse overjet at maximum protrusion. Breakages 4 Molar relationship. Table 1 – Reasons for unsuccessful treatment Canine relationship. 3 The twin block appliance was more successful than the DISCUSSION medium opening activator with 74% and 53% success The results of this audit show that the gold standard has not respectively. been met with only 71% of functional appliance treatment Appliance type % of Success (Class I incisor meeting the gold standard of a Class I incisor relationship. 6 cases relationship) (%) This result is similar to a previous audit of 73% success and 4 Twin block 81 74 greater than the 58% success reported in another audit. In 10% of cases the overjet was partially reduced, this may be Medium opening 19 53 clinically successful in cases with a large pre-treatment overjet activator or in an older patient with less growth potential. The most Table 2 – Treatment success to a Class I Incisor relationship common reason for non-successful treatment was poor patient according to appliance type. compliance due to lack of co-operation (14%), failure to attend (5%) and breakages (4%). It is difficult to motivate a patient Incremental advancement was found to be more successful however the clinician and parents should continue to do this to than a single advancement but had a longer treatment time. improve the success rates. In 6% of cases there was a lack of Advancement % of Success Length of treatment response to functional appliance treatment possibly due to poor type cases (%) (months) patient selection. One 47 57 9.2 Incremental 53 87 14.1 Nineteen percent of cases were classed as non-compliant and Table 3 – Treatment success to a Class I incisor relationship there was less than a 10% change in the overjet after 6 months. according to the advancement type. The average length of treatment for this group of patients was 12.8 months, 6.8 months more than suggested. This may be Non-compliance due to the parents or clinicians persevering with treatment Nineteen percent of the patients were classed as non-compliant, despite poor compliance from the patient, failed appointments less than a 10% overjet reduction after 6 months. Ten percent or multiple breakages due to poor wear. If there has been were therefore classed as compliant but did not achieve no change after 6 months the clinician should reassess and complete overjet reduction and did therefore not meet the consider changing the treatment plan. audit standard. In these non-compliant patients treatment was attempted for an average of 12.8 months. Most patients, 81%, were treated with a twin block appliance and 19% with a medium opening activator. The twin block was the more successful appliance with 74% reducing the overjet to Class I compared to 53% in the medium opening activator. Successful (71%) Consideration is now being given to using more twin block functional appliances in the department rather than medium opening activators. Non compliant 19% There was approximately half of the patient group that had incremental and a single advancement. Incremental Compliant but not successful (10%) advancement was more successful than a single advancement, 87% and 57% respectively. However treatment length was longer, 14.1 compared to 9.2 months. Although treatment length is increased the improved success is significant. Longer treatment may also improve long-term stability as found in a Figure 2 – Treatment compliance recent study8. Record keeping The overjet was recorded in most cases pre- and post-treatment Within the department it has been decided to use twin block but others were less frequently documented. Figure 3 shows appliances with incremental advancement due to the results of the percentage of cases were the occlusal parameters were this audit. recorded. Other than the overjet the other occlusal parameters were 100 poorly recorded in the notes at the start and end of functional 90 appliance treatment. This should be improved to enable 80 monitoring of treatment progress, treatment planning and 70 future audit collection. A proforma is to be introduced to be 60 completed at the start and end of treatment. 50 40 CONCLUSIONS 30 The gold standard set for this audit and their respective 20 outcomes were as follows: 10 1. 100% of functional appliance treatment should reduce the 0 Overjet Reverse overjet Molar Canine Overbite Centreline overjet to a Class I incisor relationship. This standard was relationship relationship not achieved as the overall success of functional appliance Start (%) Finish (%) treatment was 71%. Success rate increased for the twin block appliance that was advanced incrementally. Figure 3 - Recording of occlusal parameters 2. At least a 10% reduction of the OJ should be seen within six months.19% of patients were classed as non-compliant. 4 3. All patients should have occlusal parameters recorded 3. O’Brien, K, Wright, JL, Conboy, FM, Chadwick, S, Connolly, I, pre- and post-treatment. These parameters were often not Cook, P, Birnie, D, Hammond, M, Harradine, N, Lewis, D, McDade, recorded. C, Mitchell, L, Murray, A, O’Neill, J, Read, M, Robinson, S, Roberts- Harry, D, Sandler, J, Shaw, I, Berk, N (2003). Effectiveness of early orthodontic treatment with the Twin-block appliance: a multicenter, PLAN randomized, controlled trial. Part 2: Psychosocial effects. Am J 1. To increase the use of twin block appliances that are Orthod Dentofacial Orthop 124: 488-495 activated incrementally. 4. Kotecha S, Sidhom S (2010). An audit on the success of functional 2. Continue motivating patients to wear their appliance. appliances. BOS Clinical Effectiveness Bulletin 18: 22-24 3. If there has been little change in the overjet after 6 months 5. Sherlock J, Wong M, Powell SJ (2006). An audit of twin block treatment reassess and consider changing the treatment plan. functional appliance treatment the success rate. BOS Clinical 4. Complete a proforma pre- and post-functional appliance Effectiveness Bulletin 19: 4 treatment. 6. El-Angbawi A.M.F., Cross D.(2012). A re-audit for the success rate 5. Re-audit in 3 years. of twin block appliances in reducing overjet in Class II division 1 malocclusions in Glasgow Dental Hospital and School. BOS Clinical Effectiveness Bulletin 29: 27-29 REFERENCES 7. Banks P, Wright J, O’Brien K (2004) Incremental versus maximum 1. Chadwick SM, Banks P, Wright JL (1998) The use of myofunctional bite advancement during twin-block therapy: a randomized controlled appliances in the UK.A survey of British Orthodontists. Dental Update clinical trial. Am J Orthod Dentofacial Orthop 126: 583-8. 25: 302-8. 8. Lee RT, Barnes E, Dibiase A, Govender R, Qureshi U (2013) An 2. O’Brien K, Wright J, Conboy F, Sanjie Y, Mandall N, Chadwick extended period of functional appliance therapy: a controlled clinical S, Connolly I, Cook P, Birnie D, Hammond M, Harradine N, Lewis trial comparing the Twin Block and Dynamax appliances. Eur J D, McDade C, Mitchell L, Murray A,O’Neill J, Read M, Robinson Orthod. Ahead of print. S, Roberts-Harry D, Sandler J, Shaw I (2003) Effectiveness of early orthodontic treatment with the Twin-Block appliance: A multicentre randomised controlled trial. Part 1: Dental and skeletal effects. Am J Orthod Dentofacial Orthop 124 :234-43. 2 New Patient Satisfaction S. Nandhra Orthodontic Senior Specialist Registrar, S. Power, E. Thickett Consultant Orthodontist, Royal Bournemouth Hospital INTRODUCTION Once seen they may be referred to other providers in the In recent years a shift has taken place in the medical disciplines primary care setting. A small number of these patients have from a focus on scoring procedures from a technical stand in the past expressed annoyance at having what they perceive point to that of a patient focused outcome1 (Patient reporting to be a ‘wasted’ visit. It was decided therefore to carry out an outcome measures (PROMS)). This has been further supported audit of patient opinion of their experience at our new patient by the findings of the Francis report2. clinics.

Within orthodontic circles most PROMs have focused on AIMS patients’ satisfaction with treatment 3,4, with recent audits on The aims of this audit were to ascertain patient satisfaction with orthodontic care being approximately • If patients were being given appropriate information before 90% 5,6. However, a large proportion of the patients seen in the their appointment. new patient clinics will not be suitable for treatment within the • Whether patients were satisfied with their experience in hospital services. Therefore, their patient experience has not the orthodontic department when attending the new patient been rated to date. clinic.

We should also consider that the first interaction a patient may STANDARDS have with a hospital department is at one of our new patient • 90% of patients should receive appropiate information prior clinics. This encounter may determine the patients’ future view to their appointment. of hospital departments. • 95% patient satisfaction (would recommend the department to friends and family). Many of our patients have chosen to come to see us through the Choose and Book system. All referrals are sent to the Patient The standard for patient satisfaction was set after discussion Contact Centre (PCC) and then the patient can choose where at the departmental governace meeting. Although other audits they wish to be assessed regardless of their IOTN or their have set a standard on 90%5,6 . GDPs preference. The only information being given to them is information from their GDP and a letter from the PCC stating METHOD which providers they may choose from. If the patient chooses This was a prospective audit commencing February 2013 for a to come to the department a leaflet is sent to them about the period of three months. Data was collected on 250 consecutive department with their appointment. new patients attending the Orthodontic department of the Royal Bournemouth Hospital (RBH). A two part questionnaire Due to the strict acceptance criteria for treatment in the hospital was devised with input from all members of the orthodontic orthodontic department a large percentage of the patients seen department; this was then ratified by the patient information are not eligible for treatment in the hospital setting. Within a group (PIG) prior to use. recent departmental audit of all referrals only 26.5% of patients were placed onto the department waiting list for treatment. The first part of the questionnaire was completed as the patient entered the department and prior to being seen by the 5 orthodontist. This related to the information that the patient Question 3 “Did you know that only the more severe cases received prior to coming for their appointment and why they get treatment in the hospital?” Figure 3 graphically displays chose to come to the RBH orthodontic department. the results and shows that only 27% of patients knew that only On completion of their consultation the second part of the severe cases get treated in hospital. Of the 12 patients who had questionnaire focusing on patient satisfaction with their overall reported previous positive experience with the Orthodontic experience was completed. Results were analysed using department (Question 2) 7 knew only the more severe cases got Microsoft Excel 2007. treatment in the hospital.

RESULTS Did you know that only the more severe Two hundred and fifty patients were asked to participate in the cases get treatment in the hospital? audit (4 forms were unreturned), therefore 246 patients were included in the audit. The majority of patients seen were between Yes No Not sure the ages of 12 and 16 (55.9%), 34.7% of patients were under the age of 12, and only 9.4% of patients were over 16 years old. 16% 27% Figure 1 shows the response to “What information did you receive before booking this appointment?” Eight patients did not respond, 30 patients received more than 1 piece of information and 21 patients stated they were given no information. Therefore 29 patients (12%) received no information prior to their appointment. Forty five patients 57% selected “other”, of these 13 patients received information from the dentist. Other responses included information from siblings and the referral letter. Figure 3 Informaon received prior to aendance of Question 4 “Was the appointment made at a convenient the orthodonc department time for you?” 89.8% had the appointment made at a convient time with 3% Booklet 7% 10.2% responding no. 24% Leaflet Visit websites Question 5 “Did you find the orthodontist friendly and Informaon on 44% approachable?” 16% orthodonsts in area 6% Other 99.2% responded yes with only 2 patients (0.8%) responding No answer no.

Question 6 “Did the orthodontist explain what they were Figure 1 doing?” 100% of patients responded yes. Question 2 “Why did you choose to be seen at the department Hospital? Please rank”. Question 7 “Were you seen within 30 minutes of your There were 687 responses to this question. When ranking is appointment time?” 16 of 244 (6.7%) patients were seen after excluded from the calculation location achieved the highest 30 minutes of their scheduled appointment time. percentage (24%), with all other categories receiving a similar response except for “not sure why booked” which was 1%. Question 8 follows on from question 7 “If not, were you Figure 2 shows when ranking is included, location ranks the kept informed of the delay?” Only 3 of the 16 (19%) of the highest with other categories receiving a similar ranking. patients who were delayed were kept informed. With 7 0f 16 The most common response within the “other” category was reporting they were kept informed of the delay and 6 of 16 not the dentist had referred them and they had no choice (25 responding. patients), or the dentist recommended the hospital (4 patients). Patients also reported the RBH Orthodontic department was Question 9 “Do you have any suggestions for improvement chosen due to previous positive experiences with family or of the facilities/waiting area?”. 22 patients responded, 13 friends (12 patients). suggested no improvement, and 2 suggested toilets within the department. The other 7 responses were only suggested once e.g. childrens play area, brighter walls.

Question 10 “Are you generally happy with your visit to the department?” Only 2.5% responded no.

Quesion 11 “How likely are you to recommend our Orthodontic department to friends and family if they needed similar care or treatment?”

Figure 4 shows a graphical representation of the responses. All 244 patients responded,only 2.1% of those who responded would not recommend the Orthodontic department. 89% of those who responded were likely or extremly likely to Figure 2 recommend the department. 6 is to remain in its current guise. Therefore, a possible way of improving the situation for patients and from a resource standpoint is to liaise with GDPs and ask them to inform patients on referral where they deem may be the appropriate place for the patient to be seen.

Also the current information sent out to the patient by the hospital prior to the appointment only gives general advice about how to travel to the department and what to expect at the appointment. This is potentially a missed opportunity and it would be advantageous to reinforce the strict acceptance criteria of the hospital so that the patient has more information on the possibility of treatment at department.

ACTION PLAN • Disseminate results at Orthodontic departmental staff Figure 4 meeting. • Staff to keep patients informed if there are any delays over Question 12 followed on from question 11 and was “Please 15 minutes. can you tell us the main reason for your choice?” 124 responses • Arrange for an IOTN and referral day for refering GDPs to were received. Of these responses the only negative comment reiterate the hospitals acceptance criteria and how to best was “Due to me having to wait ages”. All the other comments inform patients when choosing and booking. were positive with the staff and the department being • Re-design patient information leaflet posted out to patients complemented. before visiting the department (hospital only treating the more complex malocclusions). The final question ”Do you have any suggestions for improving • Re-audit febuary 2015 your visit?” 15 patients responded, with 5 suggesting nothing was required; other comments were varied and included; CONCLUSIONS • 2 suggested that GDPs should provide more information on • The orthodontic department is performing well with 89% where to pick when referred to save a “wasted visit”. of those who responded likely or extremely likely to • 1 patient wrote “Unfair process of analysing of teeth”- same recommend the department. patient who was extremely unlikely to recommend the • Unfortunately of the 16 patients who were kept waiting only department to friends/ family. 3 were kept informed of the delay. • Improved communication is required with GDPs so that DISCUSSION patients may be able to more appropriately Choose and The patient satisfaction results from this audit are positive Book. with only 2.1% of patients being unlikely to recommend the department. However, only 89% of patients were likely to References recommend the department, which is below the audit standard 1. Phillips C (1999) Patient-centered outcomes in surgical and of 95%. Positive comments were received about all the staff orthodontic treatment. Semin Orthod 5: 223-30. and the services within the department, with the few negative 2. Francis R (2013) Independent Inquiry into care provided by Mid comments relating to the orthodontic departments acceptance Staffordshire NHS Foundation Trust January 2005 – March 2009 3. Nasr I, Bister D, Cobourne M (2009) Audit of patient satisfaction criteria. If it is considered that within the context of a previous with orthodontic treatment at Guy’s Hospital NHS Trust. British departmental new patient audit in 2013, that only 26.5% of Orthodontic Society Clinical Effectiveness Bulletin 23: 25-6 patients are placed onto the waiting list and 50% are discharged 4. Salam S, Caldwell S (2009) An investigation of patient satisfaction from the department, it is encouraging that patient satisfaction on completion of orthodontic treatment. A regional audit. The British is so high. The areas that could help possibly improve patient Orthodontic Society Clinical Effectiveness Bulletin 22:4-5 satisfaction would be to: 5. Hennesey J, Pringle A (2013) A reaudit to assess patient satisfaction with orthodontic treatment received within a hospital • Minimise delays in seeing patients orthodontic department. British Orthodontic Society Clinical • Keep patients informed if there are any delays Effectiveness Bulletin 31: 33-35 • Improve communcation with GDPs (i.e. advise patients 6. Stephens R, Abualfaraj R, Khan S, Hodges S (2013) Audit of when choosing and booking whether it would be more patient satisfaction with orthodontic care. British Orthodontic Society appropritae for the patient to be seen in specialist practice or Clinical Effectiveness Bulletin 30: 11-12 hospital)

The results for information received prior to attending the department is less positive with 12% receiving no information prior to attendance which falls short of the 90% standard set. Also only 27% of patients knew that only the more severe cases are eligible for treatment in hospital. Many referral letters from GDPs state that they wish for the patient to be seen in specialist practice, but the Choose and Book system overrides this and therefore they are still being seen in the hospital. There have been several conversations within our locality to attempt to resolve this; however the Choose and Book system 7 3 Patient Satisfaction with Croydon MDT Dento-Alveolar Clinics L. Khamashta-Ledezma (Senior Specialist Registrar), Z. Kordi (Senior Specialist Registrar), J. Radecki (Associate Specialist), L. Davenport-Jones (Consultant Orthodontist), M. Chia (Consultant Orthodontist), Croydon University Hospital. INTRODUCTION period following their Dento-Alveolar Clinic appointment. There is a move towards a modern patient-centred healthcare They were completed by patients if older than 16 years of age system where patient empowerment in the management of their or their parents/legal guardians if younger. These were then care, treatment and planning of services is key1. Putting Patients handed to reception staff who collated them. The questionnaire First, introduced a new system using an 11-point NHS England consisted of 28 questions with a 4 point grading scale; 1 being Scorecard, reflecting the eleven core priorities against which strongly disagree, 2 disagree, 3 agree and 4 strongly agree. The the performance will be measured, the first principle being aspects covered included satisfaction with reception, facilities, “satisfied patients”2. The document states direct feedback from staff and overall experience. A free text “comments box” was patients and their families and feedback from our staff will be the included at the end. most important measures2. Satisfaction surveys provide patient feedback, allowing their views to be taken into account when Pilot: planning service quality improvements. These have become In developing the questionnaire a pilot run was undertaken common place within NHS Trusts and are part of the Key to test the language clarity/readability and trial how the Performance Indicators (KPIs) linked to payment in primary distribution and collection of these would work most efficiently dental care services already. On average, previous audits found within our department. The questionnaire was distributed patient satisfaction with orthodontic treatment to be in the region to 9 patients who attended a clinic and their responses and of 88%-97% 3,4 and with a Joint Multidisciplinary Hypodontia comments reviewed with the Orthodontic and Oral Surgeon Clinic experience of 99%5. Consultants. The wording of some questions was revised to improve the conciseness and reduce ambiguity. At Croydon University Hospital, multi-disciplinary clinics between Orthodontics and Oral Surgery are held for patients STANDARD who require combined management. It was felt by the clinical Following review of previous comparable audits4,6, the patient team these provide a good service which is not commonly satisfaction standard was set as 90% satisfaction (scores of 3 or available in every hospital. The number of referrals to the clinic 4) in all aspects of the questionnaire. was noted to have increased in recent times. Hence, the patient’s satisfaction and suggestions were thought to be essential when RESULTS identifying ways in which to improve and develop our services. Data for 61 patients were collected and analysed. The In this case, running multi-disciplinary clinics incurs higher questionnaires were completed by patients (65%) and parents costs, is potentially more time-consuming for administrative staff (35%). The most common reason for referral was impacted and requires staff to be present from a number of specialties. canines (46%). BOS information leaflets were given to 34% of Therefore, the justification for their existence and the quality patients. All patients stated that they understood the treatment of care provided by these becomes essential when considering options, benefits and risks, their questions were fully answered increasing the number offered by a Trust. and they were satisfied with the agreed plan. Twenty three of the 28 questions asked were scored by over 90% of patients as 3 or AIMS 4, with 10 questions being scored as such 100% of the time. The aim of this audit was to assess patient/parent satisfaction with Multi-disciplinary (MDT) Dento-Alveolar Clinics with Experience in MDT Clinic Section regards to the following aspects; All patients were satisfied (scores of 3 or 4) with the experience 1. Reception: satisfaction with reception staff, registration of attending the MDT clinic, felt they were given enough process, information provided in advance (e.g. date, time, information to understand the risks and benefits of the different directions) and waiting times. options and were given an opportunity to ask questions (Table 2. Facilities: satisfaction with consultation room cleanliness, 1). Of the 98% of patients who would recommend the clinic to radiographic department arrangements and waiting room someone requiring a similar type of treatment, 43% agreed and and toilet facilities. 55% strongly agreed with this statement. 3. Staff: satisfaction with the team’s helpfulness, friendliness and communication between members of the team and 100% the patients. Information and explanations given about the 90% different treatment options and risks and advantages of all. 80% 4. Overall experience of attending the MDT Clinic: If they 70% 60% felt it was worth attending, provided them with sufficient Score 4 50% Score 3

information and would recommend it to others having a 40% Score 2 Score 1 similar procedure. 30% N/A 5. To identify areas for improvement for appropriate actions to be 20%

implemented to improve our services in all of above aspects. 10%

0% Clinical area was Given an opportunity Given enough Given enough organised and clean to ask quesons informaon and informaon and METHOD explanaons to explanaons to understand the understand the risks A prospective questionnaire based survey was undertaken opons and benefits of the different opons over 5 months, between December 2012 and May 2013 at Croydon University Hospital. Anonymous questionnaires Table 1. Patient satisfaction with the experience in the MDT were distributed to all consecutive patients during the audit Clinic. 8 MDT Clinic Team Section 100%

All patients were very satisfied with the staff they came across 90% in their MDT appointment. Ninety seven percent felt each 80% member of the team introduced themselves or were introduced 70% Score 4 making it clear who everyone was and found everyone was 60% Score 3 helpful and friendly (98%). All patients were satisfied with 50% Score 2 the communication between members of the team and with 40% Score 1 themselves (Table 2). Of the 9 questionnaires where comments 30% N/A 20% were written in the “comments box”, 7 were with positive 10% remarks and most of these related to the friendly, helpful staff 0% and excellent service. For instance, “friendly informed staff, X-ray ming If used- the If not seen on I was seen on- Waing area arrangements toilets were me- the delay me was pleasant allowed my daughter to be relaxed”, “excellent service! Very were acceptable clean and was acceptable accessible well explained”. Table 3b. Summary of questions where there was less than 100% 90% satisfaction(less than 90% with scores of 3 or 4). 90% 80% DISCUSSION 70% Score 4 Overall there was a very high satisfaction rate with the different 60% Score 3 50% aspects asked about the MDT Dento-Alveolar Clinics, as 23 of Score 2 40% the 28 questions asked were scored by >90% of patients as 3 Score 1 30% or 4, with 10 questions being scored as such 100% of the time. N/A 20% In addition, the comments reported by patients were mainly 10% praising the friendly and helpful staff and described the service 0% provided by this clinic and team as excellent. Each member of It was clear who Everyone was I/we felt the The team the team was everyone was helpful and team communicated introduced friendly communicated well with me/us well with one The questions which fell short of the gold standard (set at another 90% satisfaction) related to the facilities - toilets (88%) and Table 2. Patient satisfaction with the MDT clinic staff. waiting room décor (82%) and the waiting time for the clinic (83%) and radiography departments (83%). Although for these Reception and Waiting Room Section questions 90% of patients did not score a 3 or 4, most were Patients were satisfied with the information given in advance, between 82-88%, indicating a mild degree of dissatisfaction the welcome received and registration process (Table 3a). with the facilities. One of the most likely reasons for the However, the five questions which did not achieve the gold delay to be seen in the MDT Clinics would have been the standard were related to the facilities (toilets and décor of the overbooking of these clinics, due to the increased demand. waiting area) and waiting time to be seen in the clinic and by In the majority of cases any radiographs required tend to be the radiography department (Table 3b). The two comments requested in advance of the joint clinic. However, on occasions received with suggestions for improvement were related to these are taken on the same day which would cause a delay for reception staff, “receptionist always rude and shouts out private patients. information of patients” and the facilities at the radiograph department where there was “no appropriate seating to transfer This was a simple questionnaire to retrieve feedback on my daughter from the wheelchair to the x-ray machine”. patients’ satisfaction to help in planning improvements to our services. A pilot trial was undertaken to ensure the language Score 4 Score 3 Score 2 Score 1 N/A used was appropriate, the design was easy for patients to

100% complete and the information gathered was appropriate and

90% relevant. However, the method could have been improved by the use of a validated patient satisfaction questionnaire. 80%

70% The gold standard was set as 90% satisfaction in keeping 60% with previous audits. Satisfaction and how this is measured 50% is a complex subject as there are multiple factors which 40% would influence it such as expectations, values and previous 7 30% experiences . The latter factors are difficult to identify, quantify

20% and account for and in the scope of this audit this was not

10% attempted. Taking into account the scope of this audit, the

0% results are comparable to those of an audit undertaken to assess patient satisfaction with Joint Hypodontia Clinics5, as almost all patients felt attending had been worthwhile in both theirs (99%)5 and our audit (98%).

CONCLUSIONS Overall the patients were very satisfied with the service provided and the team involved in its provision, with 98% of patients recommending this service to others who may require a similar Table 3a. Aspects with which patients were satisfied with treatment. The only questions for which the gold standard (90% regarding reception and facilities. satisfaction) was not achieved were related to the facilities (toilets and decor of waiting area) and delays with clinics. 9 ACTION POINTS References Following discussion of the results the following action plan 1. Everyone Counts: Planning for Patients 2013/14. NHS England. was agreed; 2. Putting Patients First: The NHS England business plan for 1. Increasing the number of MDT clinics to help reduce 2013/14- 2015/16. NHS England. waiting times to be seen in this clinic and avoid overbooking 3. Seehra J, Crawford B, Carter M, Yates M, Alwash N, Ahmad S, Winchester L, Cash A (2012) Patient satisfaction following completion clinics and hence help avoid delays in seeing patients when of orthodontic treatment. The British Orthodontic Society Clinical they attend these clinics Effectiveness Bulletin No 29:2. 2. Improvements to decor of the waiting room 4. Misra S, Nazir M, Banks PA (2012) Regional audit on patient 3. Training of all reception staff satisfaction with orthodontic management during start, mid and end 4. Re-audit in 6 months of treatment. The British Orthodontic Society Clinical Effectiveness Bulletin No 28:17. Acknowledgements 5. Tams C and Ashley M (2013) Improving patient experience in a We would like to thank all the nursing and reception staff for multi-disciplinary clinic: clinical efficiency and patient satisfaction their help in distribution and collection of the questionnaires of 400 patients attending the Manchester Hypodontia Clinic. British Dental Journal 214; E11. and to the patients who kindly took their time to complete 6. Kindelan J (2000) British Orthodontic Society Audit Recipe Book. these. 7. Buthaina AA, Mohamed AAM, Maha AA, Ghaneema DA, Alaa EE, Sadad SA (2003) Patient satisfaction with three dental specialty services: a centre-based study. Medical principles and practice 12:39- 43. 4 ‘Retainers – What Retainers?’ Patients understanding of orthodontic retention: A Multicentre Audit Jenny Flanagan (Specialist Registrar) Sheena Kotecha (Consultant) Jaspal Panesar (Consultant) Birmingham Dental Hospital INTRODUCTION No alterations were required to the pilot questionnaire. Fifty The retention phase of orthodontic treatment is crucial in consecutive patients currently undergoing fixed appliance ensuring long term stability of treatment and preventing treatment at each of the five units were invited to complete relapse. The aetiology of relapse is multifactorial; contributing the 9 point questionnaire during the week commencing the factors include periodontal and occlusal factors, soft tissue 11th of March 2013. The questionnaire included (Appendix pressures and unfavourable growth patterns. 1). The patients were being treated by orthodontic consultants, registrars and clinical assistants. A wide variety of retention regimes and methods, including both fixed and removable options, are utilised by clinicians. RESULTS Although there is little agreement among orthodontists as to the In the time frame 250 questionnaires were completed (response most appropriate regime all orthodontists agree that retention is rate of 100%). a fundamental component of the treatment plan. It is essential that both patients and parents understand from the outset Overall 82% of patients were aware of the need to wear the implications and requirements of retention. Therefore, retainers following removal of their fixed appliance and 45% the commitment required in terms of retention should form were informed of the duration of retainer wear. (Figure 1) part of the informed consent process. A Cochrane review There was no significant variation between the units. (Table 1) of orthodontic retention concluded that there is insufficient evidence regarding the different types of retainers and retention 1 Gold regimes . Standard

AIMS • To assess the understanding of the need for retainers of patients currently undergoing fixed orthodontic treatment.

• To evaluate patients knowledge of the retention phase of treatment. Figure 1: Percentage of patients aware of the need to wear GOLD STANDARD retainers There are no previously defined standards in this area however, after peer consensus it was agreed that 90% of patients should Hospital Yes No be aware of the need to wear retainers following completion of WRH 46% 54% active orthodontic treatment. BDH 44% 56% MATERIALS AND METHODS UHNS 48% 52% This was a prospective multicentre audit carried out in the West B 46% 54% Midlands region with five participating units: Birmingham GH 40% 60% Dental Hospital, Worcester Royal Hospital, Burton Upon-Trent Hospital, Good Hope Hospital and the University Hospital of Table 1: Patients aware of the duration of retention North Staffordshire. A pilot questionnaire was distributed to twenty patients to assess for readability and understanding.

10 Although 65% of patients stated that they understood the A third of patients think they can have a second course of function of retainers, only 54% of patients were able to give treatment to address relapse but nearly 50% of patients are a reason for the need for retainer wear and even then the aware that this is not covered by the NHS. responses given were often incorrect. 85% of patients think that wearing retainers was well explained Overall 30% of patients felt that if relapse occurred they would to them however, given that not all patients know they be entitled to orthodontic re-treatment. The responses to this will need to wear retainers, or are aware of the function of question were similar among the participating units; with the retainers and their duration of wear and nearly half of patients exception of the Birmingham Dental Hospital where over 80% incorrectly assume they can be re-retreated in the event of of patients thought that they would be entitled to a second relapse this figure might be optimistic. It’s probable that there course of treatment. 46% of respondents were aware that if is some responder and questionnaire bias with some patients relapse occurs due to lack of retainer wear further treatment is keen to give us what they think is the correct answer. not covered by the NHS. There was consistency among the 5 units involved in the 85% of participants reported that the retention phase was well audit, with the exception being the question ‘If you do not explained to them and 63% of patients were able to recall wear your retainers and your teeth move do you think you will receiving a written information leaflet on retainers (Figure 2). be allowed to get your braces put on’. Over 80% of patients in the Birmingham Dental Hospital thought they could have re-treatment in the event of non-compliance with retention and subsequent relapse. However, when fitting retainers at the Dental Hospital patients are asked to sign a retainer consent form which reiterates to patients the importance of wearing retainers and allows clinicians to tailor make a retention regime for that patient. It also clearly stipulates that patients will not be re-treated in the event of relapse. Therefore all patients in retention should be aware of the implications of failing to comply with the retention phase of treatment.

Recommendations • Reinforce to clinicians the importance of fully consenting Figure 2: Patients able to recall receiving a written leaflet patients for retainer wear. Remind patients throughout treatment that they will be required to wear retainers when Discussion their active treatment is complete. Retainers are an important part of orthodontic treatment and • Provide written leaflets at the beginning of treatment. it is pertinent that patients are fully consented for wearing • Clinicians to advise patients that they will not be entitled retainers prior to commencing treatment. Although the majority to further treatment in the event of relapse if the retention of patients are aware of the need to wear retainers, given the regime is not adhered to. large number of patients that are undergoing treatment in • Place posters with written information on retainers in the the five participating units having 18% unaware of the need waiting rooms of the participating units. Recently at the to wear retainers is still a significant number. The need for Birmingham Dental Hospital a television screen has been set retainers is explicitly stated on the consent form so the reason up in the waiting room which explains to patients various for this finding may be that the patients cannot remember being aspects of orthodontic treatment including retainers. told about retainers at the beginning of treatment. • Unfortunately it is difficult to improve patients’ retention of information and giving patients information in as many Only 63% of patients were given a written leaflet, however ways as possible should help to keep them informed of their on analysis of the data there was little difference of patients treatment. understanding of retention between the patients that were given the leaflet and patients that were not. Previous studies Re-audit have however demonstrated that verbal information should A second cycle is planned in 12 months. be supplemented by written and/or visual information2 and it may be that the sample size in the present audit was too Conclusions small to detect a difference. 65% of patients said that they Although the majority of patients are aware of the need to knew why retainers were required but when asked to fill in a wear retainers following active orthodontic treatment, not all box explaining the reasons, a large number of patients left the patients understand the purpose and duration of retention and section blank and of those that did complete it, a significant the consequences of relapse. The need for retainers should proportion put the wrong answer. Some of the incorrect be explained as part of the consent process and reinforced answers included: throughout treatment, in particular at debond.

• Because they will push my teeth into place References • Move my jaw in line 1. Littlewood SJ, Millett DT, Doubleday B, Bearn DR, Worthington • To pull the baby tooth out and push the older tooth down HV (2009) Retention procedures for stabilising tooth position after • To maintain the shape of the teeth treatment with orthodontic braces Cochrane Database Syst Rev 25 • To open my jaw wider :CD002283. Review. • Hopefully will not need them 2. Thomson AM, Cunningham SJ, Hunt NP (2001) A comparison of information retention at an initial orthodontic consultation Eur J • Bring my teeth down to correct my bite Orthod 23:169-78. • To create gaps and reposition my bite 11 Questionnaire – Retainers

In order to continuously improve our services and patient experience at the Birmingham Dental Hospital we regularly undertake clinical audits. I would be grateful if you could take a couple of minutes to complete the questionnaire below.

1. Were you told at the beginning of treatment that you will need to wear retainers when your brace is removed? Yes No

2. Do you think wearing retainers was explained well to you when you signed the consent form? Yes No

3. Were you told how many hours a day you will need to wear your retainers to begin with? Yes No

4. Were you told how long in total you need to wear your retainers for? Yes No

5. Do you know what retainers look like? Yes No

6. Do you know why you need to wear retainers? If so why? Yes No

7. If you do not wear your retainers and your teeth move, do you think you will be allowed to get your braces put back on to straighten your teeth? Yes No

8. Are you aware that there will be a charge for having your braces again? Yes No

9. Were you given a written leaflet about retainers when you started your orthodontic treatment? Yes No

Thank You

Appendix 1 5 An Audit To Assess The Number Of Inappropriate Referrals to a Primary Care Specialist Orthodontic Practice Pritesh Raval Dental Officer, Peace Children’s Centre Watford Introduction AimS NHS orthodontic waiting list times are increasing in line The aims of this audit were to: with the demand for NHS orthodontic treatment, as there is • assess the number of inappropriate referrals sent by increasing patient education and awareness of the orthodontic referring general dental practitioners to an NHS primary treatments available1 . The average waiting list time for an care specialist orthodontist initial consultation at the practice at which this audit took • to assess why such referrals were inappropriate place was four months. A major factor for this waiting time is the number of inappropriate referrals sent to these specialist Criteria and Standard practitioners resulting in wastage of time, materials and NHS Our standard was that 100% of the referrals should be resources as well as delaying treatment for other patients. appropriate and fulfil all criteria for NHS orthodontic treatment. General dental practitioners are also becoming frustrated This is readily available from the British Orthodontic Society’s 4 with the length of time their patients are kept waiting. With guidelines for referrals document . These standards include: the new contract changes which were implemented in April • IOTN of 3.6 or above 2014, orthodontists are now, more then ever, looking to reduce • Excellent oral hygiene inappropriate referrals. • Appropriate age for orthodontic treatment • Patients knew what was expected of them and were willing The multiple NHS primary care orthodontic practitioners in to comply and cooperate this region are happy to see and treat patients who present Method with malocclusions that require routine orthodontic treatment All new referrals to the specialist orthodontic practice were to correct malocclusions that fulfil the IOTN criteria for recorded for a four month period from July 2013 to October NHS treatments (IOTN of 3.6 and above). In addition to 2013 inclusive. All the inappropriate referrals were recorded this, O’Brien’s paper of 1996 highlighted that for successful and the reasons for this noted. orthodontic treatment patients need to be the correct age for orthodontic treatment, have excellent oral hygiene, are aware The referrals were only deemed inappropriate once an 2 of what is required of them and are keen for treatment . In examination had been conducted unless it was based on age. another audit undertaken at Bradford Teaching Hospital, the The same orthodontist reviewed all new patient referrals. The number of inappropriate orthodontic referrals was found to be referrals were deemed inappropriate on the following grounds: 1 35% and in comparable audits conducted at Ipswich Hospital • Patient too young and the Royal London Hospital, the percentage of inappropriate • The patient did not meet the NHS criteria of being an IOTN 3 referrals was around 61% . of 3.6 or above • Poor oral hygiene or caries present • Patient was not willing to comply with treatment 12 Results for orthodontic treatment. The general practitioner may have a The data revealed that over this four month period, 109 new multitude of reasons as to why they are referring patients with a patients were referred to this specialist practice. Of these 109 low IOTN. The reasons could be that they are unsure as to what patients, 21 were refused treatment as the referral was deemed IOTN the patient categorises under or that they are borderline inappropriate. This equates to almost 1 in every 5 referrals and would want clarification from the specialist. They could being inappropriate. be referring due to pressure from parents or they may not necessarily want to be the bearer of the bad news. They may also feel that their experience and expertise as general dental practitioners limits them on deciding whether a patient is eligible or not for NHS orthodontic treatment. Education for general dental practitioners in NHS orthodontic referrals is therefore of paramount importance and regular post-graduate education, undertaking mandatory training or core CPD would assist in reducing the level of inappropriate referrals as this would increase awareness and confidence. It may also assist if additional audits were undertaken to further understand the reasons for inappropriate referrals. For example, an audit could be undertaken to understand what proportion of the IOTN Figure 1 – Percentage of inappropriate referrals inappropriate referrals fall into the category of referrals made due to pressure from parents. The reason for the inappropriate referrals was noted and is shown in table 1 below. As commissioning becomes increasingly regulated, it is prudent that all referrals are appropriate. It is essential Inappropriate Number of As a percentage of that hospital services do not become overwhelmed with referral reason patients the total number of practitioners referring their patients directly because of inappropriate referrals the stricter criteria that primary care orthodontists have IOTN too low 16 76% implemented, as this shifts the inappropriate referral burden Poor oral 4 19% from primary to secondary care and does not solve the hygiene problem. Patient not fully 1 5% Conclusion aware of the From this audit it is evident that there are a large number of treatment or inappropriate referrals. This should be addressed in order not willing to to improve services, waiting list times and reduce wasted comply resources. Based on the above findings, the authors make the Table 1 – Reasons for inappropriate referral following recommendations:

Discussion • All referring general dental practitioners are made aware of As is evident from the results of this audit, 19% of referrals the BOS referral guidelines can be considered to be inappropriate. The standards as set out • A proforma is used for every referral which must be ticked at the beginning of this audit are therefore not being met. As and sent by the referring practitioner before the patient is seen a result, this leads to longer waiting times, delays in starting • Further training be provided for general dental practitioners treatment for eligible patients and a wastage of NHS resources. on orthodontic referral • Discussions with the local dental committee and managed Table 1 demonstrates that of the inappropriate referrals, 76% clinical networks of them were due to the IOTN being too low, 19% due to poor • Further integration and discussions between primary and oral hygiene and 5% due to patient not being fully aware of secondary care orthodontists on their acceptance criteria for the treatment or not willing to comply. These factors can be NHS orthodontic treatments addressed and controlled by the general dental practitioner REFERENCES prior to referring the patient and if necessary, not referring 1. Marlow B, Jenkins F, Littlewood S, Houghton N (2012) An the patient or providing alternative options. This alone would Audit On The Appropriateness Of Referral Letters Received save a significant amount of time, reduce waiting list times and By Specialist Orthodontic Practitioners And The Orthodontic direct NHS resources more efficiently. Department In The Bradford Teaching Hospitals Foundation It has become apparent amongst orthodontists working in Trust British Orthodontic Society Clinical Effectiveness the primary care setting that referrals must be appropriate Bulletin 29: 20-23 and conducted in a controlled manner. This has become 2. O’ Brien K, McComb JL, Fox N, Bearn D, Wright J (1996) increasingly important due to the changes implemented in Do dentists refer orthodontic patients inappropriately? Br Dent April 2014 to contracts, which will no longer compensate for J 181: 132-136 examinations in respect of inappropriate referrals. This will in 3. Singh P, Davies I (2009) How Appropriate Are Orthodontic turn impact on key performance indicators. Referrals British Orthodontic Society Clinical Effectiveness Bulletin Clinical Effectiveness Bulletin 22: 10-11 General dental practitioners are best suited to assess a patient’s 4. The British Orthodontic Society: Guidelines for Referrals for willingness to under-go orthodontic treatment and their Orthodontic Treatment (PDF) available at http://www.bos.org. compliance as well as their overall oral hygiene levels. This is uk/Resources/British%20Orthodontic%20Society/Author%20 because they have more regular contact with the patient and Content/Documents/PDF/Referrals%20July%2009%20%20 are therefore in a better position to judge their appropriateness lo%20res.pdf 13 6 OCCLUSAL OUTCOMES FOR PATIENTS UNDERGOING ORTHOGNATHIC SURGERY IN DEVON AND CORNWALL M. Moore, K. Drage, A. Jerreat, K. Postlethwaite, R. Robinson, A. Smith, N. Wenger. South West Regional Orthodontic Audit Group (Southern Section)

INTRODUCTION rates. These two Consultants elected to use a slightly different The Peer Assessment Rating (PAR) Index1 is a valuable inclusion period from 1/7/2009 to 31/12/2011 (still 2 years 6 outcome measures for assessing patients who have undergone months). orthodontic treatment. This has also been shown to be valid for patients undergoing orthodontics in combination with The Consultants obtained “start” and “finish” PAR scores for 2 orthognathic surgery. their cases, using the normal methodology in practice in their departments, which was different in some hospitals. In Truro, PAR score outcomes for such patients in Tayside3 and also Exeter and Barnstaple, models were scored by trained and in North West England4 have previously been published and calibrated orthodontic technicians. In Plymouth and Torbay this data provides some valuable benchmarks for services to PAR models were scored by the Consultants, with some measure their own outcomes against. scoring their own cases, and others being scored by Consultant colleagues. All scorers had been trained and calibrated. The AIMS type of procedure undertaken was also recorded (single jaw To determine whether good occlusal outcomes, as determined maxilla, single jaw mandible or bimaxillary). Anonymous lists by PAR Index assessment, are being achieved for patients of cases and their scores were submitted to the lead auditor for having combined orthodontic / orthognathic surgery treatment analysis. at the hospital units in Devon and Cornwall. The start and finish PAR score was used to establish the STANDARDS numerical and percentage improvement for each case. These The standards set for the present audit were the same as used figures were used to calculate the Mean Start PAR, the Mean by McBride et al in the Tayside audit3, which in turn were Finish PAR, Mean percentage improvement and the percentage based on the O’Brien et al study4 of cases from North West of cases which achieved less than 70% improvement. The England. outcomes were then compared to the audit standards taken from the previously published studies. Each Consultant also Standard 1 received feedback about the audit outcomes for their personal Mean Pre-treatment PAR score greater than 40.48 cohort of cases.

Standard 2 RESULTS Mean Post-treatment PAR score less than 10.58 179 patients were identified as having had orthognathic surgery in Devon and Cornwall over a two and a half year period. This Standard 3 equates to a mean 10.2 cases per Consultant per annum, with a Mean improvement in PAR > 72% range from 5.7 to 18.8. Two cases could not be audited because treatment had not been completed at the time of the audit, and a Standard 4 further 2 cases could not be audited because study models were < 40% of cases achieving less than 70% improvement in PAR missing. A total of 175 cases were audited. Type of Number in Percentage O’Brien METHODS surgery present audit et al. 4 Combined orthognathic treatments are undertaken at all the Bimaxillary 105 60% 66% District General Hospitals in Devon and Cornwall, namely The Royal Cornwall Hospital, Derriford Hospital Plymouth, Torbay Maxilla only 15 9% 10% Hospital, The Royal Devon & Exeter Hospital and North Mandible 55 31% 24% Devon District Hospital (orthodontic phase only). All seven only Consultant Orthodontists in Devon and Cornwall participated Table 1. Distribution of the different types of surgery in the in the audit. present study and O’Brien et al.4

Cleft lip and palate patients from Devon and Cornwall who Audit Actual Achieved or undergo orthognathic surgery receive the surgical aspects of Standard score not achieved their care from the Cleft Lip and Palate Service South West Mean start 40.48 or 39.90 Not achieved based in Bristol and were not included in this audit. PAR greater Each Consultant was asked to collate a list of all patients who Mean finish 10.58 or less 5.63 Achieved had undergone combined orthodontic and orthognathic surgery PAR treatment under their care. To obtain a meaningful sample Mean % Greater than 85.51 Achieved size a period of 2 years 6 months was chosen. Patients were improvement 72% included if they had surgery between 1/1/2009 and 30/6/2011. 5 of cases < Less than 40% 8% Achieved Two Consultants identified that this inclusion period may 70% improved produce an atypical number of cases due to the timing of Table 2. PAR score outcomes for the entire sample of 175 their appointment to their Consultant post, or to changes in cases with reference to audit standards. departmental timetables which influenced orthognathic activity

14 Within this sample for Devon and Cornwall, the standard CONCLUSION set was exceeded for the following variables: individual Good occlusal outcomes, as determined by PAR Index consultants, finish PAR scores and mean percentage assessment, are being achieved for patients having combined improvement. Similarly, the percentage of patients achieving orthodontic / orthognathic surgery treatment at the hospital less than 70% improvement in their PAR score was units of the South West Regional Audit Group (Southern significantly better than the standard, both for the entire section). After discussion at the Regional Audit Meeting, it sample and for each Orthodontist. For the entire sample, start was felt that the Standard set here for “Mean Start PAR” may PAR scores did not achieve the audit standard of 40.48. Two have been unrealistically high, particularly bearing in mind that Orthodontists had mean start PAR scores which achieved the the earlier audit of McBride et al also adopted this as an audit standard but 5 did not. Most of those who did not achieve the standard, and also failed to meet the standard. standard for mean start PAR score were very close. In view of the large and comprehensive sample size, the results reported here may well become valuable audit standards for DISCUSSION other services to adopt when auditing occlusal outcomes for Although the routine process for obtaining PAR scores was orthognathic cases. different in different hospitals, all scorers were trained and calibrated. There seems no reason to believe that the scores Acknowledgements thus obtained are not objective. We would like to acknowledge the Consultant Oral and The geography of the Devon and Cornwall peninsula provides Maxillofacial Surgeon colleagues who contributed significantly an unusual opportunity to study a population that is unlikely to the care of the cases audited here: Mr S Adcock, Mr J to seek care out-with the locality. It would seem reasonable Bowden, Mr D Courtney, Mr D Cunliffe, Mr M Esson, Miss to conclude that the sample audited here is a very typical case L Fryer, Mr G Jones, Mr C Lansley, Mr A McLennan, Mr J mix for District General Hospital orthognathic services. The Parker distribution of the different surgical procedures is very similar to those published elsewhere which further suggests that the References 1. Richmond S, Shaw WC, O’Brien KD et al (1992) The development sample is a valid one. of the PAR Index (Peer Assessment Rating): reliability and validity. The standards adopted in the present audit were based on European Journal of Orthodontics 14:125-139 previous published studies3,4 which both had substantially 2. Templeton KM, Powell R, Moore MB, Williams AC, Sandy JR 3 (2006) Are the Peer Assessment Rating Index and Index of Treatement smaller sample sizes. The Tayside study looked at 24 cases. Complexity, outcome and Need suitable measures for orthognathic 4 The North West England study captured 94 patients but only outcomes? European Journal of Orthodontics 28: 462-466 71 had complete sets of data. It is not clear from that paper how 3. McBride A, McIntyre G, Laverick S, Hoban D (2012) Improvements many patients of the 94 had complete PAR scores available. in occlusal outcomes for patients undergoing orthognathic surgery. The 175 cases audited here were treated in 5 hospitals, by 7 The British Orthodontic Society Clinical Effeciveness Bulletin 27: Consultant Orthodontists working with 10 Consultant Oral and 3-4. Maxillofacial Surgeons. As such the audit reflects a wide range 4. O’Brien K, Wright J, Conboy F et al (2009) Prospective, of clinical practice. multicentre study of the effectiveness of orthognathic care in the United Kingdom. American Journal of Orthodontic and Dentofacial Orthopaedics 135:709-14.

7 ORTHOGNATHIC SURGERY PRECISION – A RETROSPECTIVE AUDIT OF PLANNED AND ACTUAL MOVEMENTS DURING MAXILLARY SURGERY Hannah Barrya, Preeyan Shahb, Hashmat Popatb and Andrew Cronina aUniversity Dental Hospital, Cardiff & Vale University Health Board bSchool of Dentistry, Cardiff University INTRODUCTION AIM Orthognathic treatment planning is a multi-disciplinary To assess the difference between planned and actual skeletal approach, with the orthodontist, surgeon and technician change during maxillary surgery using hard tissue landmarks working closely together to provide the best possible outcome. on lateral cephalometric radiographs. There are several methods available to plan orthognathic surgery and these techniques have become more accurate STANDARD and sophisticated over the past few decades. Traditionally, Based on previous published literature in the field, surgically planning was carried out by hand tracing lateral cephalometric planned hard tissue landmark positions (x, y) should be within radiographs but more contemporary approaches use computer- 2mm of the actual surgical outcome3. Therefore the standard simulated software. There are however several sources of error adopted for this audit is that 90% of surgical procedures should that can lead to inaccuracies in the final surgical outcome. deliver the planned position of the maxilla to within 2mm. Lateral cephalometric tracing (landmark identification/analysis) and superimposition can cause mean errors in horizontal and PROCESS/MATERIALS AND METHODS vertical dimensions of more than 0.5mm1. Impression taking, This was a retrospective audit that compared the pre-surgical face-bow recording, model articulation and surgical splint and post-operative lateral cephalometric radiographs for fabrication have been shown to have a combined error of up to patients that had maxillary surgery (single jaw or part of a 1mm2. It is therefore important to compare planned surgical bimaxillary osteotomy) from January 2010 to December 2011 movements with actual outcome so that discrepancies in the at the University Dental Hospital in Cardiff. care pathway can be identified. In this manner the quality of Patients were included if they had pre-surgical and post- care provided to the patient can be monitored. operative lateral cephalometric radiographs available along 15 with a clear surgical plan written in the notes. Movement Mesiobuccal U1 tip Patients were excluded from the audit if they had cleft lip or cusp U6 palate deformities or other soft and hard tissue abnormalities that may have previously been corrected, isolated genioplasty Dx Dy Dx Dy or rhinoplasty procedures. Patients who had surgical assisted (mm) (mm) (mm) (mm) rapid maxillary expansion or other transverse skeletal Maxillary advancement 2.7* 0.2 0.2 0.6 corrections were also excluded. (n=8) 2.2* 2.8* 0.3 1.4 All radiographs were taken digitally in the same department using a Sirona Orthophos 3 machine. The pre-surgical 0.2 1.1 0.1 0.4 radiographs were taken following orthodontic decompensation, 1.6 1.6 1.0 0.2 and post-operative radiographs were taken between 2 and 6 weeks after surgery. Radiographs were uploaded onto Dolphin 1.0 0.4 0.3 1.3 Imaging™ Version 10 (Patterson Dental Supply) software 1.1 0.9 2.2 0.3 programme at the same resolution (1280 x 1024 pixels). All pre-operative and post-operative radiographs were traced by 1.6 0.8 0.2 0.4 one person using the Eastman Analysis. 0.8 0.1 0.7 0.6 The pre-surgical radiograph was superimposed onto the post-operative radiograph on the Sella-Nasion line at Sella. Mean 1.1 0.7 0.6 0.7 The differences in the x-y position of the mesio-buccal cusps Maxillary impaction (n=4) 1.2 0.9 0.1 3.0* of maxillary first permanent molar and the incisal edge of the maxillary central incisors between the pre- and post-operative 0.3 0.5 0.0 0.6 radiographs were recorded. These values represented the actual 0.8 0.2 0.0 0.6 surgical movements that occurred and were compared to the planned surgical movements as documented in the clinical 0.2 0.3 0.0 0.6 notes. In calculating the mean differences between the planned Mean 0.6 0.5 0.0 0.6 and actual surgical outcome, the sign of the difference was overlooked as the sum of positive values (i.e. over-correction) Maxillary 1.2 2.2* 0.0 3.1* advancement and and negative values (i.e. under-correction) would eliminate 2.2* 2.5* 0.2 1.0 each other leading to an overestimate of accuracy. Therefore all impaction (n=5) values were converted to a positive sign for transparency. 0.1 1.1 0.4 0.8 Intra- and inter-observer reliability was assessed by two of the 1.1 0.9 0.7 1.6 authors (PS and HP) re-tracing 10 of the radiographs chosen by a random number generator a week later. Mean method error was 2.8* 0.2 0.4 0.4 highest for the mesio-buccal cusp of the upper first permanent Mean 0.8 0.7 0.3 0.9 molar in the x-plane at 0.9mm for inter-observer reliability. Maxillary differential 0.2 1.6 1.1 2.5* impaction (n=4) RESULTS 1.7 2.3 3.7* 1.9 Overall, 24 maxillary procedures were carried out. The distribution of differences and means between the planned 1.9 0.3 0.3 0.1 movements and outcome for each case is shown in Table 0.8 0.1 0.2 0.6 1. In total, 9 cases fell short of the standard leaving 63% of cases delivered to within 2mm of the surgical plan. Planned Mean 1.1 1.1 0.5 0.9 horizontal maxillary molar and incisor movements (x) tended Maxillary 2.0 0.1 0.6 2.6* to be more accurate when compared to vertical movements advancement and (y) as shown in Table 1. The variations between the planned differential impaction 0.2 0.8 0.3 0.1 and actual movement were overall more accurate for the (n=3) 1.0 2.2 1.7 0.6 upper incisor when compared to the maxillary molar. Single movement maxillary procedures (i.e. advancement or Mean 1.0 1.0 0.9 0.4 impaction) were more accurate than multiple movements (e.g. Combined Mean 0.9 0.8 0.5 0.7 advancement and impaction). Table 1 Differences in hard tissue positions between the planned movements and outcome (* indicates audit standard not met)

16 DISCUSSION CONCLUSION/PLAN Overall the audit standard was not met with 9 cases falling This audit has highlighted that 37% of maxillary movements outside the criteria of within 2mm between planned and actual in this sample of cases were outside 2mm of their predicted movement. The results of this audit are less favourable to those position in either the horizontal and/or vertical directions. found in other studies3, 4 however the manner in which the These represented the more complex movements, particularly results are interpreted should be considered. In developing a differential maxillary impactions, are more likely to show standard, cases in this audit have been taken on an individual variability with the position of the maxilla. A reliable method level, whereas in research studies mean values have been of controlling the vertical height of the maxilla could improve quoted. As can be seen from this audit, if only the combined on the accuracy of this procedure – currently the surgeon mean discrepancies were taken into consideration then the uses soft silicone surgical splints – hard acrylic splints will audit standard would have been met fully with all hard tissue now be specified for multi-directional maxillary movements. movements within 2mm of the actual plan. On an individual Additional information such as patient reported outcome level, combined movement of the maxilla were least accurate measures and occlusal indices would be useful to supplement with only 50% of cases meeting the standard (6/12 cases). the information collected as part of this audit. For example did Single movements of the maxilla had an accuracy of 75% (9/12 the inaccuracies found in this audit impact on the outcome at cases). the clinical or patient level? This audit will be repeated in 12 months time with this additional information to complete the All lateral cephalometric radiographs were taken within 6 audit cycle. weeks post-operatively but minor movements due to finishing orthodontics may have skewed the results slightly. This REFERENCES however was not a factor under control of the audit as clinical 1. Trpkova, B. et al. (1997). Cephalometric landmarks identification need presided. and reproducibility: A Meta-analysis. American Journal of Orthodontics and Dentofacial Orthopedics 112: 165-170 Sources of error should also be considered with landmark 2. Schwestka-Polly, R. et al. (1998). Techniques for achieving three- identification having the potential to influence the accuracy of a dimensional positioning of the maxilla applied in conjunction with surgical outcome particularly since superimposition and a lack the Gottingen concept. International Journal of Adult Orthodontics & Orthognathic Surgery 3: 248-258 of detail in some areas of a cephalograph can make consistent 3. Jacobson, R. and Sarver, D.M. (2002). The predictability of identification for subsequent images difficult. In the audit maxillary repositioning in LeFort I orthognathic surgery. American conducted, horizontal and vertical discrepancies were greatest Journal of Orthodontics and Dentofacial Orthopaedics 122 :142-154 for the maxillary molar mesio-buccal cusp tip. This is most 4. Choi, J.Y. et al. (2009). Surgical Accuracy of Maxillary likely due to superimposition but may also be due to poor detail Repositioning According to Type of Surgical Movement in Two-Jaw in this area when compared to the incisor region. Additionally Surgery. Angle Orthodontist 79: 306-311 variation in the width of the first maxillary molar can make 5. Pospisil, O. A. (1987). Reliability and feasibility of prediction identification more difficult. Comparably, the accuracy of tracing in orthognathic surgery. Journal of Cranio-Maxillofacial horizontal incisor placement can be attributed to more control Surgery 15: 79-83. 6. Power, G. et al. (2005). Dolphin Imaging Software: an analysis over the position of the central incisors and the horizontal of the accuracy of cephalometric digitization and orthognathic position playing an essential role in the overall aesthetic prediction. International Journal of Oral & Maxillofacial Surgery 34: 3 outcome . 619-626. 7. Sharifi, A., Jones, R., Ayoub, A., Moos, K., Walker, F., Khambay, The vertical position of the maxilla is also important but there B., & McHugh, S. (2008). How accurate is model planning for is some scope for movement and the surgeon may change orthognathic surgery? International journal of oral and maxillofacial the vertical position during surgery. Pospisil et al reported surgery 37: 1089-1093 that 33% of surgical inaccuracies resulted from a change in the surgical plan5. This may be due to unforeseen factors, anatomical variation (e.g. Pterygoid plate inclination), surgical complications and aesthetic reasons.

Landmark identification may not be consistent due to difficulties in tracing the cephalometric radiograph. However hand tracing, particularly when conducted by the same examiner, can provide consistent and comparable cephalometric readings. Power et al concluded that for majority of points, Dolphin Imaging™ can provide readings that are comparable with hand tracing but for a number of points it is less reliable and this must be considered as a source of error6.

Sharifi identified inaccuracies with the face bow recording, the intermediate wafer, and auto-rotation of the mandible in the supine or anaesthetized patient to be the principal reasons for errors in orthognathic planning. The maxilla tended to be under-advanced and over-impacted anteriorly when compared to predictions from the model surgery. However, none of these differences were statistically significant7.

17 8 Orthodontic mini-screw effectiveness in Leeds S. K. Barber (Specialty Registrar in Orthodontics), D. O. Morris (Consultant Orthodontist) Leeds Dental Institute, Leeds Introduction Results Mini-screws, also known as Temporary Anchorage Devices A total of 75 mini-screws were placed; 15 in the palatal (TADs) or mini-implants, provide additional anchorage in a maxilla, 42 in buccal maxilla and 18 in the mandible. variety of cases. Mini-screws can be used in cases with reduced InfinitasTM (DB Orthodontics) screws were used in all cases. support, such as periodontally-involved adults and hypodontia Consent was obtained for all patients, although written patients, orthognathic cases, as well as in routine cases for information was not recorded as having been provided for antero-posterior support for labial segment retraction, molar two mini-screws placed in one patient (97% compliance). distalisation, space closure, vertical support for intrusion and Documentation that discussion of the procedures and risks had extrusion of teeth and transverse support to aid correction of taken place was recorded for 100% of patients. centre-lines and alteration of the occlusal plane1. Stability of the mini-screw is gained from mechanical retention Eleven mini-screws were still in situ at the time of data analysis. rather than osseo-integration. A number of factors can affect Of the 64 mini-screws that had been removed, 30 (47%) were stability2: removed early due to failure and 34 (53%) were electively • Patient factors: age, mandibular plane angle, smoking status removed once anchorage requirements were met. Success • Local factors: maxilla or mandible, anterior or posterior, rates for mini-screws were 54% in the mandible and 50% in the buccal or palatal, gingival attachment, presence of maxilla. The national success rate, obtained from the June 2013 inflammation British Orthodontic Society audit report, was 79%. • Implant design: length, diameter, self-tapping or self-drilling • Insertion technique: placement torque, clinician experience, proximity of root

Successful mini-screw placement has been defined as: “static force tolerance for 6 months to one year”. Screws with minor mobility can, however, still be successful3. Variable success rates have been reported, ranging from 78.6% to 93.6%4. It is essential that the success rate of mini-screws is closely monitored and audited, to identify problems, aid learning and, most importantly, to ensure a high level of patient care.

Aims The objective of this audit was to determine the effectiveness of orthodontic mini-screws placed within Leeds Teaching Hospitals NHS Trust • To identify success and failure rates Figure 1 shows the reported causes of mini-screw failure. The • To identify complication/adverse response rates majority of failures were due to mobility (19 mini-screws) and/ • To compare the success rate in Leeds with the results of the or inflammation (9 mini-screws). Infection was a reported on-going BOS national audit 5 complication for two mini-screws.

Standards The gold standards used in the on-going BOS national mini- screw audit, which are based on NICE guidelines, were employed: • Written information given to patients 100% • Documented discussion re: procedures and risks 100% • Signed consent form 100% • Screw lost/removed before anchorage completed <20% • Anchorage provided without adverse effects >70% • Infection/inflammation around screw resulting in loss <20% • Damage to neighbouring tooth 0% • 70% overall success rate (80% in maxilla, 60% in mandible)

Materials and Methods The audit was undertaken in the Orthodontic Departments Figure 2 shows the reported adverse effects of all mini-screws of Leeds and Seacroft Hospitals. Each clinician collected placed, regardless of whether the mini-screw was successful. data prospectively at the time of mini-screw placement and Adverse effects were reported in 30 of the 64 mini-screws removal using a standardised data capture sheet. The period (47%) in which full anchorage provision was achieved. The of data collection extended from July 2008 – July 2013. All most commonly reported adverse effects were mobility and patients who underwent mini-screw placement were included inflammation, seen in 21 and 12 mini-screws respectively. One in the audit. If the data form was incomplete, the data was mini-screw was recorded as having caused root damage to obtained from the original clinical records where possible. One adjacent teeth. individual (DOM) was responsible for uploading the data to the BOS. 18 VARIABLE SUCCESS FAILURE STILL IN TOTAL Excessive torque at the time of insertion has been identified SITU as one of the main limitations to successful mini-implant 6 Time of loading insertion. One recent study found that torque levels were affected by the gender of the operator and the muscle groups Delayed 4 (5%) 6 (8%) 3 (4%) 13 (17%) used. Furthermore, success with mini-screws is often related Immediate 25 (32%) 21 (27%) 18 (23%) 64 (83%) to clinician experience7, with junior staff experiencing less Clinician level success (50%) than more senior staff (94.4%). It is likely that Consultant 3 (4%) 7 (9%) 7 (9%) 17 (22%) clinician inexperience will have contributed to the high failure Post-CSST 6 (8%) 8 (10%) 6 (8%) 20 (26%) rate in Leeds. The large proportion of “mobile” mini-screws Specialty 20 (26%) 12 8 40 (52%) reported infers poor technique and/or high torque levels. The Registrar (15.5%) (10.5%) early data collected (2008) for this audit was at a time when all clinical staff were similarly unfamiliar with mini-screw Site placement. Trainees are now supported to attend a high quality Palatal maxilla 3 (4%) 7 (9%) 5 (6%) 16 (21%) training course prior to placement of any TADs but as, a larger Buccal maxilla 18 (23%) 14 (18%) 11 (14%) 43 (56%) proportion of mini-screws are being placed by the trainees, the Mandible 7 (9%) 6 (8%) 5 (6%) 18 (23%) failure rate remains relatively high. Age of patient <20y 20 (26%) 4 (5%) 9 (12%) 33 (43%) Plan 20-30y 5 (6.5%) 12 5 (6.5) 22 • Continued advice that all trainees should attend a high (15.5%) (28.5%) quality training course prior to using mini-screws • Specific work-based assessments for mini-screw placement >30y 4 (5%) 11 (14%) 7 (9%) 22 (28.5%) are to be introduced for all trainees to aid teaching and help Table 1: Success and failure rates of mini-screws (number to improve placement technique and %) separated by variables • Ensure all clinicians are using the correct screw for the COMPARISON BETWEEN GROUPS P VALUE particular bone site and that the insertion protocol is being followed correctly Immediate loading Delayed loading 0.49 • Clinicians to consider being “less adventurous” with what Consultant Post-CSST trainee 0.68 they hope to achieve with mini-screws until their retention Consultant Specialty Registrar trainee 0.14 rates have improved Palatal maxilla Buccal maxilla 0.31 • Clinicians to re-think the possible mechanics involved in a Maxilla Mandible 1 case with respect to direct or indirect anchorage and using the anterior palate site to achieve higher success rates8 <20y old 20-30y old <0.001* • The audit is to be continued with a further review of results 20-30y old >30y old 1 in 12-18 months time <20y old >30y old <0.001* Table 2: Results of the Fisher’s exact test, used to identify Acknowledgements any significant associations between variables and success / Many thanks to Professor David Bearn and Fahad Alharbi for failure rates. providing the national data. (* indicates statistical significance as p<0.05) References Discussion 1. McGuire MK, Scheyer ET, Gallerano RL (2006) Temporary The 47% failure rate found for mini-screws placed in Leeds anchorage devices for tooth movement: a review and case reports. J exceeded the audit target of <20% and was considerably Periodontol 77: 1613-24. higher than the results from the BOS national audit. Similarly, 2. Cousley RJ (2013) The Orthodontic Mini-implant Clinical adverse events were reported in 30 of the 64 mini-screws Handbook: John Wiley & Sons. (47%) in which full anchorage provision was achieved. This 3. Park HS, Jeong SH, Kwon OW (2006) Factors affecting the clinical success of screw implants used as orthodontic anchorage. Am J exceeds the audit gold standard set of <30%. Orthod Dentofacial Orthop 130: 18-25. 4. Moon CH, et al. (2008) Factors associated with the success rate Compliance with consent and documentation in notes was of orthodontic miniscrews placed in the upper and lower posterior excellent at 100%. However, the finding of 97% compliance buccal region. Angle Orthod 78: 101-6. for provision of written information fell short of the audit 5. Bearn D, Alharbi F (2013) National TAD (Temporary Anchorage standard. Adverse effects were reported in 30 of the 64 mini- Device) Audit .British Orthodontic Society. screws (47%), including one case where damage to the root of 6. Estelita S., et al. (2012) Selective use of hand and forearm muscles an adjacent tooth. These results do not reach the audit standard during mini-implant insertion: a natural torquimeter. J Orthod 39 : of >70% of mini-screws being free of adverse effects, with no 270-8 7. Cousley R (2011) A re-audit of orthodontic mini-implant success damage to neighbouring tooth. Success rates for mini-screws rates. British Orthodontic Society Clinical Effectiveness Bulletin 26: 7-9 were 54% in the mandible and 50% in the maxilla, failing to 8. Berens A, Wiechmann D, Dempf R (2006) Mini- and micro-screws achieve the audit standards of 60% and 80% respectively. for temporary skeletal anchorage in orthodontic therapy. J Orofac Orthop 67:450-8 Statistical analysis indicate that only patient age appeared to be associated with outcome, with the younger age group having significantly higher success rates than the older groups. This is surprising as it is generally thought that the reduced cortical thickness and density and higher bone remodeling in younger patients reduces success rates2.

19 9 A REGIONAL AUDIT TO ASSESS THE SURGICAL RE-EXPOSURE RATES OF ECTOPIC PALATAL MAXILLARY CANINES A. Gill1, R. Valiji Bharmal1, T. McSwiney1, M. Palarajah2, B. Bagdadi3, C. Campbell1. John Radcliffe Hospital, Oxford1, Heatherwood and Wexham Hospital, Slough2 and Stoke Mandeville Hospital, Buckinghamshire3 INTRODUCTION Ectopic maxillary canines are frequently encountered by both general dental practitioners and orthodontic specialists. It is the second most commonly impacted tooth, after the mandibular third molar, with a prevalence of 0.92%-2.4%1-3. Palatal impaction is approximately three times more likely than buccal impaction4. The aetiology of the ectopic maxillary canine is multifactorial, due to either genetic factors or local factors such as peg shaped or absent lateral incisors, crowding or retained deciduous teeth.

Management of established canine impaction often requires both orthodontic and surgical intervention. Palatally impacted canines can be surgically treated with either an open or closed exposure technique. Immediately following open exposure a Figure 1: Comparison of open/closed exposure percentages periodontal dressing (Coe pak) or coverplate is often placed between the various regional units whereas a gold chain is bonded to the impacted canine during 87 (45%) open exposures. Overall, the re-exposure rate was the closed exposure technique. Many studies claim advantages 4.6%. 5-6 and disadvantages of each exposure technique , however a For those canines undergoing closed exposure, 2 out of 105 recent Cochrane Collaboration Systematic Review was unable canines required re-exposure (2%). In both cases failure was to find any evidence to support the use of one technique over attributed to debonding of the gold chain. 7 the other . In contrast, for canines undergoing open exposure, 7 out of 87 canines required re-exposure (8%). In all cases failure was Occasionally a second surgical procedure may be required due to soft tissue overgrowth following the initial exposure. to expose the impacted maxillary canine. Common causes Individual surgical re-exposure rates varied across the regional of re-exposure include soft tissue overgrowth or gold chain units: Unit 1 - 4.5%; Unit 2 - 2%; Unit 3 - 14%; Unit 4 - 0%. debonding. On review of the literature it appears that surgical re-exposure rates of impacted maxillary canines vary between DISCUSSION 8-10 2%-6% . This audit showed that the overall surgical re-exposure rate of ectopic maxillary palatal canines was 4.6%, which meets the AIMS: gold standard. Similar figures ranging from 2%-6% have been The aims of this audit were to investigate: shown in other regions in the UK8-10. • The surgical re-exposure rates of palatal maxillary canines in the Oxfordshire, Berkshire and Buckingham region. The re-exposure rate for closed exposures of 2% (2 out of 105 • The reasons for surgical re-exposure. canines) in this audit, is identical to that recorded by Gutierrez et al at Chesterfield Royal Hospital8. Both failures, due to STANDARDS gold chain debonding, occurred at Unit 1, where canines were The gold standard for surgical re-exposures should be <5% as bonded by surgeons using self-etching primer from 3M Unitek. 5-6 determined by previous reports . No failures were recorded at the other units. At both Unit 2 and Unit 3 gold chains were bonded using a 2 stage etch and METHOD primer bonding technique. Patients included in this audit were from four regional Oral and Maxillofacial Surgery Units in the Oxfordshire, Berkshire and In our audit, the re-exposure rate for open exposures of 8% (7 Buckinghamshire region; Unit 1, 2, 3 and 4. out of 87 canines) falls below the gold standard. In addition, Patients were referred by both primary care and secondary care it is higher than that reported by Ponduri et al. (6%) at the specialist orthodontists. Data were collected retrospectively Queen Alexandra Hospital, Portsmouth9. All failures were due for all patients undergoing palatal canine exposure between to soft tissue overgrowth. On further analysis it was noted that October 2011 and September 2012. Patients were identified Unit 3 accounted for 5 of these failures with the remaining from theatre logbooks and minor oral surgery lists. Patients two failures occurring at the Unit 1 and Unit 2. In 5 of the 7 were only included if all written case records were available. failure cases, no cover plate was provided. This audit did not Patients were excluded if the position of the canine was not assess whether adequate bone/soft tissue was removed at the recorded or the patient records could not be located. time of surgical exposure or the post operative oral hygiene of the patient, which would also account for failure in the open RESULTS exposure group. One hundred and sixty-eight patients in total were identified that met the inclusion criteria. 57% of patients were female and 43% male. In total, 192 palatal canines were exposed (Figure 1). These comprised 105 (55%) closed exposures and

20 Our study highlighted a difference in re-exposure rates between REFERENCES the open and closed technique. This is in contrast to the 1. McSherry PF. (1998) The ectopic maxillary canine: a review British Cochrane Review, where no difference in surgical re-exposure Journal of Orthodontics 2:209-216 rates was concluded for the two techniques7. 2.Erickson S, Kurol J (1986) Radiographic assessment of maxillary One limitation of this audit is that we were unable to follow up canine eruption in children with clinical signs of eruption disturbance. European Journal of Orthodontic 8:133-134 cases referred from primary care. In these cases, success was 3.Kramer RM, Williams AC (1970) The incidence of impacted teeth. recorded if the cases were not re-referred for re-exposure. A survey at Harlem hospital. Oral Surgery, Oral Medicine, Oral Pathology 29: 237-240 CONCLUSIONS 4.Fournier A, Turcotte JY, Bernard C (1982) Orthodontic • The surgical re-exposure rate for maxillary palatal canines considerations in the treatment of maxillary impacted canines. met the gold standard (4.6%) American Journal of Orthodontics 81:236-239 • The surgical re-exposure rate was lower for the closed 5.Burden DJ, Mullally BH, Robinson SJ (1999) Palatally ectopic exposure technique (2%) than the open exposure technique canines: Closed eruption versus open eruption. American Journal of (8%) Orthodontics and Dentofacial Orthopaedics 115: 634-639 6.Ferguson JW, Parvizi F (1997) Eruption of palatal canines following • The underlying reasons for re-exposure were gold chain surgical exposure: A review of outcomes in a series of consecutively debonds and soft tissue overgrowth treated cases. British Journal of Orthodontics 24:203-207 7.Parkin N, Benson PE, Thind B, Shah A (2008) Open versus closed RECOMMENDATIONS surgical exposure of canine teeth that are displaced in the roof of the • Use of coverplate may be preferable in an open exposure mouth. Cochrane Database of Systematic Review, Issue 4. technique 8. Gutierrez R, Doyle P, Orr R, Sandler J (2012) An audit to assess • Re-audit in 2 years the re-exposure rate of impacted maxillary canines following the closed exposure technique. The British Orthodontic Society Clinical Effectiveness Bulletin, 27: 6-7 9.Ponduri S, Robinson S (2006) An audit to assess the re-exposure rates of maxillary canines. The British Orthodontic Society Clinical Effectiveness Bulletin 19:6 10. Chambers C, Walker C, Morrant D, Pilley J (2010) An audit to assess the re-exposure rate of impacted maxillary canines treated with a closed exposure technique. The British Orthodontic Society Clinical Effectiveness Bulletin 24 :19-20

10 Documentation of the Basic Periodontal Examination scores as part of the orthodontic examination for new patients: A two- cycle audit A. Hindocha, N. Patel, J. Turner, S. Visram. Birmingham Dental Hospital Introduction new patient assessment in order to avoid orthodontic treatment Numerous studies have reported on the onset of gingival in cases where periodontal disease is active. inflammation with fixed appliance therapy. Erricsson et al. (1978) showed that the use of fixed appliances in a patient with Although patients in the permanent dentition would be an inflamed periodontium may lead to definite angular bony suitable for a full BPE, a lower age limit of 20 was chosen as defects1. It is therefore important to diagnose and manage recommended by Ainamo et al. (1984) in order to allow the 4 appropriately pre-existing periodontal inflammation in patients best use of limited resources . prior to fixed appliance therapy2. An assessment of each patient’s oral hygiene status alone is insufficient as periodontal Aims disease may be due to a non-plaque aetiology such as defects 1. To identify whether patients aged 20 and above have a Basic in neutrophil function or connective tissue metabolism. The Periodontal Examination (BPE) carried out in new patient examination of radiographs aid in the diagnosis of bone consultant orthodontic clinics. loss, however, it is not indicative as to whether the condition 2. To ascertain whether appropriate onward referrals are made has been treated or is pre-existing. The basic periodontal in order to manage pre-existing periodontal disease. examination (BPE) has been shown to be a quick and effective method of diagnosing the disease and is a systematic method Gold Standard of examining for the presence of periodontal disease and The British Society of Periodontology (2001) states that all quantifying its severity3. new patients attending dentists for the first time should have a BPE recorded5. The gold standard for recording a BPE score General dental practitioners should ensure that patients are at the time of assessment in adult patients was therefore set to caries free, periodontally stable and can sustain a level of 100%. oral hygiene that is sufficient to support orthodontic therapy prior to referral to the orthodontist. Unfortunately this is not always the case, and therefore without a periodontal screen to ascertain level of disease, it is possible for patients to commence orthodontic treatment with pre-existing periodontal disease. Many patients are referred in for possible active treatment rather than advice and it was therefore felt that a basic periodontal examination would be useful as part of the

21 Changes to clinical practice BPE Interpretation Management Following completion of the first cycle, the results and score information on actions to be implemented were disseminated 0 No pockets >3.5 mm, no No need for periodontal to the orthodontic team at the Birmingham Dental Hospital calculus/overhangs, no treatment and the consultants in the West Midlands at the regional audit bleeding after probing meeting. Several changes were made in order to encourage (black band completely clinicians to perform a BPE examination as part of their routine visible) examination. The new patient assessment proforma sheet was modified to include a section for documentation of the BPE 1 No pockets >3.5 mm, no Oral hygiene instruction calculus/overhangs, but (OHI) scores and the addition of a WHO probe was made to the bleeding after probing examination kits. (black band completely visible) SECOND CYCLE Method: 2 No pockets >3.5 mm, OHI, removal of plaque The second cycle consisted of examination of 90 clinical but supra- or subgingival retentive factors, calculus/overhangs (black including all supra- and records of patients aged 20 and above seen in new patient band completely visible) subgingival calculus orthodontic clinics between January 2013 and June 2013 All data collected in the first cycle was included in the second 3 Probing depth 3.5-5.5 OHI, root surface cycle, and also a note made of which proforma sheet was used mm (black band partially debridement (RSD) (original or modified). visible indicating pocket of 4-5mm) Results The age of patients was similar to the cohort in the first cycle 4 Probing depth >5.5 mm OHI, RSD. Assess the with the majority being between the age of 20 and 39. Fifty- (black band entirely within need for more complex the pocket, indicating treatment; referral to five out of 90 patients (61%) had a BPE recorded. Of these pocket of 6mm or more) a specialist may be 55 records, 43 used the updated proforma and 12 used the old indicated. proforma sheet. Onward referrals for addressing the periodontal condition were made for 13 patients: eight referrals were made * Furcation involvement OHI, RSD. Assess the to the GDP and 5 referrals were made to the department of need for more complex periodontology at the Birmingham Dental Hospital. The oral treatment; referral to hygiene status was recorded for all patients. a specialist may be indicated. Comparison of the 1st and 2nd cycle Table 1: Adapted from British Society of Periodontology document on BPE6. FIRST CYCLE Method: This was a retrospective audit looking at the clinical records of 90 patients who had attended for assessment in the Orthodontic Department of the Birmingham Dental Hospital. The cohort of patients aged 20 years and above that were audited were seen in new patient consultant orthodontic clinics between January and June 2010. The following data were collected: 1. Age of the patient at the time of the consultation 2. Evidence of a BPE examination 3. Record of the oral hygiene status Figure 1: Results of initial audit and second cycle 4. Grade of the clinician examining the patient 5. Evidence and type of onward referral to manage periodontal disease, if justified Results • Sixty percent of the patients were seen by registrars and 30% were seen consultants. Ten percent were seen by clinical assistants. • Six percent of patients had the BPE recorded • Eighty three percent of the patients had an OH status recorded • The majority of the adult patients examined in the audit were aged between 20 and 39 with 70% aged between 20 and 29. • Onward referrals for addressing the periodontal condition were made for 8 patients: five of those were to the GDP and the remaining 3 were to the periodontology department Figure 2: Results of the second cycle also demonstrate in the Dental hospital. Three referrals were made in the what proportion of records had a BPE recorded when the absence of BPE scores. modified proforma sheet was used. 22 Figure 1 shows that records of 90 patients were examined Recommendations for both cycles. There was an improvement for all variables • Only the new proforma sheet with the ‘BPE prompt’ box examined which included the documentation of the oral should be used on the new patient clinic. The old proforma hygiene status and recording of the grade of clinician. A sheet has been removed from the department. significant improvement was made in the recording of BPE • All staff need to be reminded that all new adult orthodontic from 6% in the first cycle to 61% in the second cycle and patients need to have a BPE screen. a concomitant increase in the number of referrals for the management of the periodontal condition in the second cycle. Acknowledgements: Orthodontic Team at Birmingham Dental Hospital Figure 2 shows that 45 of the 55 BPE records were made in the revised proforma sheet and 12 of the 35 were made in the REFERENCES previous proforma sheet. 1. Erricsson I, Thilander B, Lindhe J (1978) Periodontal conditions Discussion after tooth movements in the dog . Angle Orthod. 48: 210-8 2. Sanders NL (1999) Evidence based care in orthodontics and The results of both cycles showed that the documentation periodontics: a review of the literature. J Am Dental Assoc 130 :521-7 of BPE fell short of the gold standard, however there was a 3. Tugnait A, Clerehugh V, Hirschann PN (2004) Use of the basic significant improvement for the recording in the second cycle. periodontal examination and radiographs in the assessment of The number of referrals for the management of the periodontal periodontal disease in general dental practice. J dent 32: 17-25 condition also increased in the second cycle, possibly through a (viewed on 17/12/2013 at 11:40am) greater number of patients diagnosed with periodontal disease. 4. Ainamo J, Nordblad A and Kaliko P (1984) Use of CPITN in This highlights the effectiveness of the updated proforma sheet populations under 20 years of age. Int Dent J 34:285-291 and the raised awareness as a result of disseminating the results 5. Periodontology in general dental practice in the United Kingdom, from the 1st cycle and implementing changes to encourage A policy statement (March 2011), British Society of Periodontology. http://www.bsperio.org.uk/publications/downloads/64_144208_ clinicians to perform a BPE. periodontology-in-general-dental-practice-in-the-uk.pdf (viewed 17/12/2013 at 11:40am) The introduction of the new proforma sheet and supply 6. Basic periodontal examination, British Society of Periodontology of WHO 621 and CPITN probes in exam packs has been guidance (Oct 2011) http://www.bsperio.org.uk/publications/ successful in improving compliance with current guidelines. downloads/39_143748_bpe2011.pdf (viewed 17/12/2013 at 11:40am) Conclusion 1. There has been a modest improvement in the recording of the BPE scores although it still falls short of the gold standard. 2. The revised proforma sheet has encouraged clinicians to record the BPE. 3. A greater number of referrals have been made as a result of the increase in the number of patients diagnosed with periodontal disease. 4. This audit highlights the need for a re-audit following distribution of the results of the re-audit to the orthodontic team at Birmingham Dental Hospital. 11 An audit on patient experience following orthognathic surgery M. W. Tang (Senior House Officer), A. Dibiase (Consultant Orthodontist) William Harvey Hospital, Ashford, Kent INTRODUCTION positive experience of care. Orthognathic surgery is an elective Orthognathic surgery is increasingly popular as a treatment of procedure. It is therefore particularly important to assess choice for patients with abnormal dentofacial relationships. It patient experience to help provide a patient centred service and requires delicate team work between Orthodontists and Oral improve the provision of care. and Maxillofacial Surgeons to correct maxillary-mandibular relationships, improving facial appearance and function. AIM This treatment has also been reported to improve self esteem To assess patient experience following orthognathic surgery and transform social life for patients1. Many studies describe the technical aspects and clinical outcomes of the surgical OBJECTIVES procedure. The measure of ‘success’ that is relevant to the To assess patient experience of immediate post-surgical patient however is largely subjective and reliant on individual symptoms and care received patients’ perspective. Assessing their journey through this To assess patient satisfaction of information provided prior to surgery is therefore pertinent in measuring overall success. surgical intervention STANDARDS Furthermore, there is an increasing emphasis on patient 100% of patients should feel they were fully informed prior to centred care as the NHS moves away from process targets surgical intervention which should be reflected in their reported to measuring outcomes as highlighted in The White Paper: post-operative experience. Liberating the NHS2. One of the domains included in The NHS Outcomes Framework 2013/143 is to ensure that people have a

23 METHODS patients (80%, n=8) who experienced difficulty breathing found Patients who had undergone orthognathic surgery (Bimaxillary it to be more than expected. 70% (n=7) of the patients rated this Osteotomy, Le-Fort 1 Osteotomy, Bilateral Sagittal Split to be ≥3 on a scale of 1 to 5 where 5 is very frightening. Osteotomy (BSSO)) between January 2012 and May 2013 were identified from laboratory records of wafer production. Recovery Prior to the commencement of this study, a letter was sent out 41% (n=13) of patients reported that recovery took longer than to all patients regarding our intention to carry out a telephone expected while for 44% (n=14) and 15% (n=5) of patients, the survey to assess their experience with orthognathic surgery and recovery was as long as and shorter than expected respectively. the overall care received. Patients were given an option to opt- out of the survey should they wish not to be contacted and this 75% (n=24) of patients report at least one or a combination of would not affect their on-going care. residual problems since surgery as shown in Table 2. A modified version of a validated questionnaire4 was used and Residual problem Number of patients (%) a copy of this was also attached with the letter. Patients who did not opt out were contacted by telephone at least one month Difficulty eating 4 (12.5) after being discharged from the hospital following surgery to Numbness 19 (59) complete the survey. All answers to the questionnaire were recorded by one investigator for consistency. Other: 10 (31)

The information collected was entered on to a coded data Table 2 – Residual problems reported by patients collection sheet which was kept securely and separately from the main patient information to protect patient confidentiality. Other reported residual problems are jaw aches (n=1), jaw clicks (n=2), nose bleeds (n=1), blocked nose (n=1), poor RESULTS occlusion (n=2), exposed metal plate (n=1), swelling and The total of 33 patients underwent orthognathic surgery occasional pain (n=1) and speech problems (n=1). between January 2012 and May 2013. Of these, 32 patients Problems at home were successfully contacted to complete the questionnaire, The main issue patients had at home were problems with giving a response rate of 97%. 75% of respondents (n=24) eating. A patient reported not knowing what types of foods had bimaxilary osteotomy while 12.5% (n=4) had Le-Fort 1 were appropriate. The majority however attribute this problem Osteotomy and BSSO respectively. to swelling and pain which is also related to problems with Post-operative symptoms sleeping. Two patients also had problems with painkillers provided by The reported post-operative symptoms in relation to patient the ward. They could not swallow the tablets provided and expectations are shown in table 1. therefore did not have appropriate pain relief at home. Other issues raised were difficulty with oral hygiene, unexpected nose With symptoms Without bleeds and difficulty with placing elastic bands. Symptoms More As Less than Total with Motivation for surgery than expected expected symptoms 59% (n=19) of patients stated improving facial appearance to expected be one of the motivations of undergoing orthognathic surgery. Other reasons stated are to improve speech (n=2), ability to Pain 8(25) 8(25) 16(50) 32(100) 0 eat (n=10), self confidence (n=3) and align jaw (n=10). Three patients stated ‘orthodontist advised’ as their sole reason for Swelling 23(72) 8(25) 1(3) 32(100) 0 treatment.

Bruising 11(34) 6(19) 10(31) 27(84) 5(16) Pre-operative information Patients generally felt that they were ‘well’ or ‘very well’ Difficulty 12(38) 16(50) 2(6) 30(94) 2(6) informed about the surgery and overall treatment as shown in eating Figure 1.

How well informed did you feel about your treatment? Breathing 8(25) 1(3) 1(3) 10(31) 22(69) difficulty 16 14 Numbness 13(41) 15(47) 2(6) 30(94) 2(6) 12 Table 1 – Reported post-operative symptoms in relation to 10 patient expectations 8 6 Data are number (%) of patients 4 All patients who underwent orthognathic surgery experienced 2 post-operative pain and swelling. The majority however reported 0 12345 the pain to be less than expected while swelling was reported to Well informed ------Poorly informed be more than expected. The reported level of pain on a scale of

1 to 5 had a normal distribution. Numbness and difficulty eating Well informed about surgery? Well informed overall? has the same reported incidence and were both largely more than Figure 1 – Patients perception of information provided or as expected. 94% of patients reported difficulty in eating and prior to surgery only 41% (n=13) of patients reported that the food provided on the ward was appropriate ‘most of the time’. The majority of 24 The ultimate test of satisfaction is whether patients would severity of long-term side effects such as numbness changes choose to undergo the same surgery if they could choose again. as time progresses and therefore the reported numbers may 78% of patients said they would have undergone the surgery not be reflective of true incidence. The time lapse between the knowing what they now know (Figure 2). surgery and survey also introduces re-call bias. Operator bias is however minimised by having all surveys conducted by one Knowing what you now know, would you still have investigator. undergone the surgery? CONCLUSION • The telephone survey achieved a response rate of 97%, proving it to be an effective method of surveying patients. • Patients are well informed about post-operative pain, and 4 this is managed effectively. 3 Yes • Patients need to be better informed about post-operative swelling, bruising and difficulty breathing. No • The ward needs to be more aware of patients needs and serve appropriate food. 25 Unsure • The main problems faced by patients at home were mainly related to dietary needs. • Orthognathic surgery provides an overall benefit to patients’ well being. 78% of patients would still choose to undergo the surgery having been through it. 87.4% and 85% of Figure 2 – Patients reported willingness to undergo patients felt well informed about the surgery and overall orthognathic surgery having been through surgery procedure respectively. DISCUSSION The response rate for the survey is very high at 97% (n=32) PLAN due to the method of survey. A telephone survey method was • Design a post-operative care leaflet to be given to patients chosen due to the relatively small sample size and ability of before the surgery so they can be prepared for the post- obtaining qualitative data through this method. None of the operative care required. patients opted out of the telephone survey and one patient • Discuss with ward manager to provide education on failed to respond due to wrong telephone number provided in management of patients following orthognathic surgery, their hospital records. particularly relating to dietary needs. • Re-audit patient experience after one year to see if the The majority of patients reported less pain than expected changes implemented improve patient experience. post-surgery possibly due to effective pain relief provided at • Re-audit patients who were interviewed to review post- the hospital and on discharge. This is also reflective of the operative problems and changes in their view towards their information provided prior to surgery which prepares patients experience after a longer period of time. for post-operative symptoms. Patients need to be better informed about the swelling and difficulty breathing that can REFERENCES be expected post-surgery as 72% and 80% of patients with 1. Lazaridou-Terzoudi T, Kiyak HA, Athanasiou AE, Melsen B (2003) symptoms reported this to be worse than expected respectively. Long-term assessment of psychologic outcome of orthognathic Information given about difficulty eating and numbness post- surgery. Journal of Oral and Maxillofacial Surgery 61: 545—52 operatively can be improved as approximately 40% reported 2. Department of Health (2010) Equity and excellence: Liberating the this to be ‘more than expected’. NHS. The Stationery Office Limited. 3. Department of Health (2012) The NHS Outcomes Framework 2013- The provision of appropriate food in the wards needs 14. Available at: http://www.dh.gov.uk/en/Publicationsandstatistics/ improvement as only 41% of patients reported this to be Publications/PublicationsPolicyAndGuidance/DH_117353 appropriate most of the time. 6 patients complained that they 4. Travess HC, Newton JT, Sandy JR, Williams AC (2004) The were served inappropriate foods such as fish and chips on the development of a patient-centered measure of the process and outcome of combined orthodontic and orthognathic treatment. Journal of ward. Orthodontics 31: 220-234 Even though 75% (n=24) of patients still experience a residual 5. Williams RW, Travess HC, Williams AC (2004). Patients’ problem since the surgery, 78% (n=25) of patients would still experiences after undergoing orthognathic surgery at NHS choose to undergo the surgery having been through it. We can hospitals in the south west of England. British Journal of Oral and deduce from this that patients gained overall benefit from the Maxillofacial Surgery 42: 419—431 surgery despite post-operative complications. The overall reported post-operative experience falls short of the gold standard (100%) as a proportion of patients reported symptoms to be worse than expected for all symptoms investigated. Despite this, patient satisfaction with the information provided regarding the surgery and overall procedure was 87.5% and 84% respectively. This trend in relatively high satisfaction with information provided despite worse post-operative symptoms than expected is similar with results from other comparable studies5. This study is at risk of bias as there is a wide variation in time since the patients were operated on. It is known that the

25 12 A REGIONAL AUDIT OF ORTHOGNATHIC SERVICE PROVISION AND TREATMENT DURATION A. Tsichlaki1, S. Ward2. University Dental Hospital Manchester1, Royal Blackburn Hospital2 Introduction audited / n total): Royal Blackburn Hospital (41 /49), Fairfield Patients potentially requiring combined orthodontic and General Hospital, Bury (10 /10), University Dental Hospital orthognathic treatment are initially asked to attend a joint of Manchester (13/14) and Stockport NHS Foundation Trust / clinic for further treatment planning. During this visit, further University Hospital of South Manchester (13 /26) information is offered regarding the procedures involved and The discrepancy between the numbers audited and the total their risks and benefits. In addition, an estimation of anticipated numbers were mainly due to the availability of notes and duration of the various treatment stages is given. Knowledge patients being unidentifiable from the surgical lists, which of treatment process and duration are important not only resulted in their notes being irretrievable. for service organisation and treatment planning, but also for informed patient consent to be valid1. It has also been found Standard 1 that accurate information and communication is likely to result The mean overall treatment time with appliances was 31.7 in patients being more satisfied with their overall treatment2,3. months (SD 11.3) for all the hospitals combined. Only one hospital had a greater than average treatment duration of 38 Aims months, whereas for the remaining hospitals this averaged The aims of this audit were to evaluate the process of combined within the standard of 30 months (Figure 1 Mean overall orthodontic-surgical treatment across hospital units in the North appliance duration (months)). Overall only 53% of patients West of England and determine whether any improvements to met the gold standard to have treatment completed within 30 the service need to be made. months. None of the hospitals achieved the individual target of having 90% of their patients achieve this target. (Table 1. Standards Percentage of patients (n=77) achieving standards). There are no set national guidelines as to what constitutes a gold standard for treatment duration, so the gold standards for Standard 2 this audit were devised from similar published studies in the The mean overall waiting time for surgery was 4.1 months (SD UK4-6. 3.1) for all the hospitals combined. One hospital had a much higher than average waiting time of around 7 months, while for It was agreed that 90% of patients should meet the following the remaining 3 hospitals the wait was between 3 - 4.5 months targets: (Figure 2. Mean wait for operation (months). 1.Total treatment should be completed within 30 months Overall 70% of patients met the gold standard of having to wait 2.When ready for surgery no patient should wait more than 4 no more than 4 months for surgery and 2 hospitals achieved the months target of having 90% of their patients achieve this (Table 1). 3.Fixed appliances should be removed within 6 months after surgery Standard 3 The mean overall duration of the post-operative orthodontic Materials AND Methods treatment was 5 months (SD 2.7) for all the hospitals We carried out a multicentre retrospective regional audit of all combined. There were mild variations across the hospitals, patients having undergone orthognathic surgery between 1st with means ranging between 4.8 - 5.5 months (Figure 3. Mean January 2011 and 31st December 2011 inclusive. This enabled post-operative orthodontic treatment duration (months)). a post-operative period of at least one year during which the Overall 77% of patients met the gold standard of having their orthodontic treatment should have been completed. The dates braces removed within 6 months after surgery, but only 1 of the various stages of treatment were retrieved through hospital had 90% of their patients meeting this target (Table 1). reviewing clinical notes and this information was recorded on a The average number of surgery cancellations (=0.1) and nights data collection sheet. Data were collected by one author visiting of hospital stay (=2.1 nights) were similar across all units. the different units, with the exception of one hospital which submitted their own data. Dates were recorded for the following: Hospital Standard 1 Standard 2 Standard 3 initial contact, joint clinic, bond-up, end of decompensation % (n) % (n) % (n) phase, pre-operative joint clinic, surgery and debond. Number of RBH (41) 62 (23/37) 90 (35/39) 77 (27/35) operation cancellations and nights of hospital in-stay were also recorded on the same proforma. No information was recorded FGH (10) 20 (2/10) 90 (9/10) 90 (9/10) regarding the treating clinicians, surgeons and procedures UMDH (13) 73 (8/11) 50 (6/12) 73 (8/11) undertaken, as this was not always practical. Data were analysed in SPSS v20 using descriptive statistics. UHSM/SHH 30 (3/10) 15 (2/13) 69 (9/13) (13)

Results Total (77) 53 (36/68) 70 (52/74) 77 (53/69) Data were collected from five regional hospitals, however, University Hospital of South Manchester is the surgical Table 1 Percentage of patients (n=77) achieving standards provider for orthognathic treatment undertaken at Stockport NHS Foundation Trust as well, so data are presented jointly for these two centres. A total of 77 patient notes were identified and audited. Statistics on numbers of patients audited from each hospital together with the total number of patients having undergone surgery in that year are shown below (n

26 consultant in one unit during the period we audited, lack of available surgeons, as well as a possible delay in transferring cases between these two centres for the joint clinics and surgery. The lack of a permanent consultant could mean that there were not robust systems in place to ensure that the pathway of combined orthodontic-surgical cases was smooth. Finally, there were large variations in the numbers of surgically treated cases across the four units, but this requires further assessment in terms of clinicians, clinician grades and surgeons available in each unit for future service planning (i.e. allocation of post-CCST trainees to units with larger volumes of orthognathic surgery cases). However, in this audit we assessed Figure 1 Mean overall appliance duration (months) all patients undergoing surgery over one year so any inherent variability in numbers and cases may possibly reflect different service pressures across the units. It would be useful to engage more units in the region in future auditing cycles in order to evaluate the combined process in North West England more comprehensively. Conclusion / Action Plan Standards were only met for the post-operative orthodontic duration lasting less than 6 months. Overall targets were not achieved but individual hospitals did achieve some. However, the caseload per unit needs to be assessed and explored further in order to enable better workforce planning. Individual hospitals need to also explore the possibility of proactively booking the joint clinic appointment approximately 12 months Figure 2 Mean wait for operation (months) after the start of orthodontic treatment to help reduce overall treatment times, although understandably, this may not always be practical. All units need to ensure that patients receive accurate information regarding anticipated duration of the various stages of treatment at the joint clinic appointment. Currently, it is recommended that, patients should be told that overall treatment is expected to take around 32 months give or take a couple of months. The two centres with the combined surgical service should also consider setting up joint clinics in both units, in order to reduce delays in the process occurring as a result of transfers between the centres, or potentially increasing the number of available surgeons and clinicians to minimize delays in surgery waiting times and overall treatment, respectively. A second cycle Figure 3 Mean post-operative orthodontic treatment will be completed again in 36 months time to evaluate any duration (months) improvements in the process, and since some of the staffing issues would have already been addressed, it is anticipated that Discussion results will be improved. In our region, the gold standard was only met for the mean post-operative treatment duration and orthodontic treatment Acknowledgements was completed on average within 5 months following surgery. We would like to thank Mr P. Banks for his data contribution This was shorter than that reported by Jeremiah et al4 and on Fairfield General Hospital, Bury. Luther et al6, of 7.2 and 7.5 months respectively. Although our standards for overall treatment duration lasting no more than 30 References months and mean wait for surgery less than 4 months were not 1. Jones W (1999) A medico-legal review of some current UK met, our results are comparable to those in the East of England guidelines in orthodontics: a personal view. Br J Orthod. 26: 307-324 2. Cunningham S, Hunt NP, Feinmann C (1996) Perception of region4, who reported a mean overall treatment time of 32 outcome following orthognathic surgery. Br J Oral Maxillofac Surg. months, similar to our finding of 31.7 months and mean wait 34: 210-13 for surgery of 3.5 months, slightly less than our finding of 4.1 3. Kiyak HA, Wes RA, Hohl T, McNeill RW (1982) The psychological months. However, it is worth noting that we did not collect data impact of orthognathic surgery: A 9-month follow-up. Am J Orthod on reasons for possible delays in surgery and overall treatment 81: 404-412 and it is possible that some patients would have chosen to 4.Jeremiah HG, Cousley RR, Newton T, Abela S (2012) Treatment time purposely delay this, in order to arrange it at a time of most and occlusal outcome of orthognathic therapy in the East of England convenience (i.e. during holidays). region. J Orthod 39: 206-211 In our audit sample, however, the two units which have a single 5. Luther F, Morris DO, Hart C (2003) Orthodontic preparation for orthognathic surgery: How long does it take and why? A retrospective surgical service provider seemed to have much longer than study. Br J Oral Maxillofac Surg 41: 401-6 average waiting times for surgery and consequently overall 6. Luther F, Morris DO, Karnezi K (2007) Orthodontic treatment treatment time, which may be considered unacceptable. Possible following orthognathic surgery: How long does it take and why? A reasons for this include the lack of a permanent orthodontic retrospective study. Br J Oral Maxillofac Surg 65: 1969-1976 27 13 AUDIT OF PATIENT DIETARY HABITS S.L. Stephens, R.M. Stephens, S.J. Cunningham and F.S. Ryan Eastman Dental Hospital UCLH Foundation Trust and UCL Eastman Dental Institute INTRODUCTION 1. Patient demographics; age and gender. A diet which has a low frequency intake of non-milk extrinsic 2. The aetiology of dental caries; this section asked patients sugars (NMES) is important in reducing the risk of dental what they thought caused tooth decay and provided a list of caries. Patients wearing fixed orthodontic appliances are potential options. They were advised to tick as many options considered to be at greater risk of decalcification and dental as they thought applied. caries due to the increased risk of plaque accumulation around 3. Dietary habits; this section asked patients if there were any brackets and bands, on composite surfaces, and on interfaces foods they avoided whilst wearing fixed appliances. It also between the composite and enamel1. Sugars from the diet asked what they usually drank at meal times and in-between are metabolised in this plaque resulting in demineralisation meals. and, if the lesions progress, dental caries2. Thus, as well as 4. Consequences of inappropriate dietary advice; this section maintaining a high level of oral hygiene, orthodontic patients asked patients what they thought would happen if they ate or are required to maintain a diet which is low in the frequency drank the wrong things during orthodontic treatment. and amount of NMES. 5. Information provision; the final part of the questionnaire asked patients if they felt they had been given enough In addition, orthodontic patients are encouraged to avoid foods information regarding what to eat and drink whilst wearing a that are likely to damage their appliances as this may in turn brace. prolong their treatment; the common instruction being to avoid hard and sticky foods. Dietary advice is routinely given at With the exception of the first and final section of the orthodontic appointments, however recent research within this questionnaire there was a list of responses following each department identified that 50% of patients would like more question and patients were asked to tick all options that information on how fixed appliances affect eating3. were correct or applied to them. Patients were also given the opportunity after each question to write additional information AIMS if their responses were not included. For the final part of The aims of this audit were four fold: the questionnaire patients were invited to make comments 1. To assess patients’ dietary habits whilst undergoing fixed regarding the information they had received during treatment. appliance treatment. 2. To assess patients’ knowledge of the cause of dental decay. The questionnaire was then piloted on five patients to assess 3. To assess patients’ knowledge of the consequences of acceptability and readability. Changes made following the pilot inappropriate dietary habits whilst undergoing fixed included minor modifications to wording. The Flesch reading appliance treatment. ease score for the questionnaire was 80% which represents a 4. To determine whether patients feel they have been provided suitable reading level for the average 10 year old. with sufficient information about what to eat and drink whilst wearing fixed appliances. Questionnaires were handed out to 60 consecutive patients over a two day period. Patients were included in the audit if they were DESIGN AND SETTING undergoing treatment involving fixed orthodontic appliances This was a prospective questionnaire audit carried out over a with orthodontic specialty registrars. There were no restrictions two week period in January 2012 in a postgraduate teaching on age or medical history. Patients were excluded from the audit hospital. if they had not yet started treatment, were having treatment involving removable appliances only, were in retention or were AUDIT STANDARDS attending for a review appointment. Patients were asked to There were no set standards available in the literature; however complete the questionnaire at the end of their appointment. the importance of dental health education and the restriction of sugary food and drink consumption in preventing dental caries RESULTS has been documented in the literature4. The audit standards The response to the questionnaire was 83%. Fifty patients were set by the authors following discussions at a departmental completed the questionnaire of which 64% were female and audit meeting prior to data collection: 36% were male. The majority of the patients were aged 15-18 • 100% of patients should appreciate the importance of years old (42%), 30% were aged between 12-14 years and 16% limiting the intake of sugary foods, hard foods and fizzy were between 19-25 years of age. Twelve percent were aged drinks. Drinks containing sugar should be limited to meal 26 years or older. The results of questions number 3 to 9 are times only. presented in tabular format (Tables 1-7). • 100% of patients should be aware of the aetiology of dental caries and consequences of inappropriate dietary practices Causes of tooth decay % whilst wearing fixed appliances. Plaque / food build up 84 • 80% of patients should feel they have been provided with Not cleaning teeth properly 78 the ideal amount of information about correct dietary Sugar 74 practice whilst wearing fixed appliances. Bugs / bacteria 34 It happens over time anyway 8 SUBJECTS AND METHOD It runs in families 6 A questionnaire consisting of nine questions was designed Other 0 by the authors (Appendix 1). There were five parts to the Table 1. Responses to Question 3: What do you think questionnaire which included: causes tooth decay? 28 The majority of patients were aware that tooth decay is related Drink % to plaque, inadequate cleaning and consumption of sugar. Water 84 Approximately a third of patients were aware that bacteria Fruit juice 36 play a role in tooth decay and a small number of patients thought that tooth decay was a family trait and would happen Fruit squash 30 eventually over time. Fizzy drinks 22 Flavoured water 18 Food % Food % Tea or coffee with sugar 12 Toffee 62 Nuts 24 Tea or coffee without sugar 8 Sweets 50 Biscuits 20 Milk 6 Hard fruit 42 Crunchy cereals 20 Flavoured milkshakes 4 Other 0 Dried fruit 40 Crackers 14 Table 4. Responses to question 6: What do you drink at Hard raw vegetables 38 Crisps 10 meals times while wearing a brace? Meat on bone 36 Cereal bars 8 Crusty bread 26 Other 20 Water was the most popular drink for meal times. Approximately a third of patients drank fruit juice and fruit Chocolate 24 None 16 squash, and fewer than a third of patients drank fizzy drinks or Popcorn 24 flavoured water at meal times. A small percentage of patients drank tea or coffee with their meals, with more patients adding Table 2. Responses to question 4: Are there any foods you sugar to this type drink. Only six percent of patients drank milk avoid eating whilst wearing a brace? at mealtimes and even fewer drank flavoured milkshakes. Over half of patients avoided toffees and a half of patients avoided sweets. Just under a half of patients avoided hard fruit Consequence % or dried fruit. Fewer than a third of patients avoided chocolate, Break the brace 58 nuts and biscuits and fewer than 15% avoided crackers, crisps Stain the teeth 52 and cereal bars. Twenty per cent of patients avoided foods that Cause tooth decay 42 were not listed in the questionnaire (“other”) but unfortunately no comment was made on what these foods were. Damage the teeth 34 Make the brace treatment longer 30 Drink % Wear away the teeth 16 Water 84 Make bad bugs / bacteria in the mouth 16 Fruit juice 46 Scar the teeth 12 Fruit squash 42 Braces have to be taken off before the teeth are fully 8 straight Fizzy drinks 28 Nothing 6 Flavoured water 24 Other 2 Tea or coffee with sugar 22 Table 5. Responses to question 7: What happens if you eat Tea or coffee without sugar 18 or drink the wrong things whilst wearing a brace? Milk 16 The most frequent responses to question 7 were breaking the Flavoured milkshakes 14 brace or staining the teeth. Fewer than a half of the patients were aware that an incorrect diet caused tooth decay or caused Other 0 damage to the teeth. Just under a third of patients thought that Table 3. Responses to question 5: What do you drink in- an incorrect diet would increase treatment time. A smaller between meals whilst wearing a brace? number of patients thought an incorrect diet would lead to tooth wear or presence of bacteria in the mouth and 8% recognised The majority of patients drank water in-between meals but that a poor diet may result in braces being taken off before the just under a half of patients drank fruit juice and fruit squash. teeth were fully straight. Fewer than a third of patient drank fizzy drinks, flavoured water, tea and coffee in-between meals. Slightly more patients Correct amount of information on dietary habits % drank tea or coffee with sugar than without. Milk, followed by Yes 78 flavoured milkshakes, were the least popular choice of drinks in-between meals. No 22 Table 6. Response to question 8: Do you think you have been given enough information on what to eat and drink whilst wearing a brace?

Seventy eight percent of patients felt that had been given the correct amount of information on dietary habits.

29 mealtimes would be beneficial in patient education. Patients Comments made % may not have the ability to retain the initial verbal information No comments 66% provided and it is important to repeat this information during Comments 34% treatment in order to improve information retention. This includes educating both patients and parents and ensuring Table 7. Response to question 9: How can we improve the that they have read the relevant British Orthodontic Society information given to you on what to eat and drink whilst information leaflets provided. wearing a train-track brace? The final question asked patients for any additional comments RECOMMENDATIONS and 34% of patients did add comments. These included: The majority of patients felt they had received adequate dietary • “I am happy with what my orthodontist has told me” advice. However, dietary habits and awareness about the • “Provide a list of what to avoid eating” cause of dental caries were obviously not adequate and could • “Give me a leaflet” be improved amongst patients within the department. The following recommendations have been made: DISCUSSION A greater number of female patients responded to the 1. Continue to identify dietary risk factors prior to questionnaire; this is likely to be due to the majority of commencing orthodontic treatment. orthodontic patients being female5,6. The majority of patients 2. Reinforce verbal dietary advice throughout treatment. were aged between 15 and18 years of age, which would be 3. Dietary advice should include providing patients with expected in a NHS teaching hospital. information on appropriate dietary habits and the The results show that not all patients had ideal dietary habits, consequences of inappropriate dietary habits. thus the audit standard was not met. Surprisingly over half 4. Ensure written information on dietary advice is easily of patients still continued to eat sweets and toffees during accessible to all patients and ensure patients have read the fixed appliance treatment. Although the majority of patients relevant information. drank water, fizzy drinks were more likely to be consumed 5. Educate parents as well as patients on good dietary practice in-between meals rather than at meal times. The British as adolescent orthodontic patients are likely to seek advice Orthodontic Society advises that oral hygiene advice, oral from their parents3. hygiene instruction and use of fluoride supplements should 6. Re-audit to assess the impact of recommendations. be carried out by orthodontists in order to minimise the risks of dental decay7. In this department, verbal dietary and oral REFERENCES hygiene advice is routinely provided at the start of treatment 1. Gwinnett JA, Ceen F (1979) Plaque distribution on bonded and the relevant information leaflets are also provided. The brackets. American Journal of Orthodontics 75:667-677. extent of reinforcement during treatment will depend upon the 2. Levine RS, Stillmam-Lowe CR (2009) The scientific basis of oral individual patient and treating clinician. health education. London. BDJ Books. 3. Stephens RM, Ryan FS, Cunningham SJ (2013) Information seeking behaviour of adolescent orthodontic patients, American Journal of The audit standard for awareness of the aetiology of dental Orthodontics and Dentofacial Orthopedics 143: 303-309 caries and the consequences of inappropriate dietary practice 4. Scottish Intercollegiate Guidelines Network (2000) Preventing during fixed appliance treatment was not met. Patients did dental caries in children at high caries risk, targeted prevention of not appear to have a full understanding of what causes dental dental caries in the permanent teeth of 6-16 year olds presenting for decay despite the information provided to them at the start of dental care. www.sign.ac.uk. treatment. They were more likely to associate decay with a lack 5. Sheats RD, McGorray SP, Keeling S, Wheeler TT , King, GJ (1998) of tooth brushing rather than poor dietary habits. Additionally, Occlusal traits and perception of orthodontic need in eighth grade patients were more likely to associate an inappropriate diet students. Angle Orthodontist 68: 107-114. 6. Wedrychowska-Szulc, B, Syrynska, M (2010) Patient and parent with fixed appliance breakages rather than with dental decay. motivation for orthodontic treatment – a questionnaire study. Advice on how to avoid fixed appliance breakages may European Journal of Orthodontics 32: 447-452. be repeated more frequently during treatment rather than advice on caries prevention, therefore it is also important for clinicians to also remind patients of the other consequences of inappropriate dietary practices.

The majority of patients felt that they have been provided with adequate information on correct dietary habits during fixed appliance treatment; however this was not reflected in their dietary habits and their knowledge of the consequences of inappropriate dietary habits, thus the audit standard was not met. With regards to patients being provided with sufficient information, the audit standard was not met at 78% but it was close to the 80% gold standard. Twenty-two percent of patients said they would have liked more information on what to eat and drink whilst wearing fixed appliances. A small number of patients suggested providing a written list of what food and drink to avoid whilst undergoing treatment. While it would be difficult to provide a comprehensive list of all foods and drinks to avoid, written guidance on avoiding certain types of foods and drinks (such as hard chewy foods and fizzy drinks) and advice on restricting non milk intrinsic sugars and acids to 30 Appendix 1

Number……

QQuueessttiioonnnnaaiirree ffoorr ppaattiieennttss wweeaarriinngg ttrraaiinn--ttrraacckk bbrraacceess Please could you spend a few minutes of your time to fill in this questionnaire?

WeWe are are interested interested in infinding finding out out what what you you know know about about cleaning clean your what teeth you and eat what and you drink eat whilstwhilst wearingwearing a brace. a brace. This is This so we is socan we try can and try improveand improve our ourpatient patient care care in inthe the future. future.

SECTION 1: ABOUT YOU

a. Are you?

 Male  Female

b. How old are you?

…………………

SECTION 2: EATING AND DRINKING

a. What do you think causes tooth decay? (TICK AS MANY THAT YOU NEED TO)

 Plaque/food build up  It happens over time anyway

 Not cleaning teeth properly  Bugs / bacteria

 SugarAppendix 1  Other (please

 It runs in families describe)……………………………………………………………………………………

…………………………………………………………………………………………………. f. Do you think you have been given enough information on eating and drinking while wearing a train-track brace? b. While wearing braces are there any foods you avoid eating? (TICK AS MANY THAT YOU NEED TO)  Yes  No

 Noneg. How can we improve the information givenCrusty to bread you about& pizza diet crusts and what to eat and drink when wearing a train-track brace?  Chocolate  Hard fruits e.g. apples, pears ……………………………………………………………………………………………………………………………………………………………………………………………… Biscuits Hard or chewy dried fruits e.g. dried bananas, dried mango  ………………………………………………………………………………………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………………… 1 ………………………………......

TThhaannkk yyoouu ffoorr ffiilllliinngg tthhiiss iinn!!

Please return this questionnaire to your orthodontist, reception or you can post it back to: 31 Miss S Stephens, Orthodontic department, Eastman Dental Hospital, 256 Grays Inn road WC1X 8LD

3

Appendix 1

 Sweets e.g. boiled or chewy sweets  Hard raw vegetables e.g. carrot sticks, celery

 Toffee  Nuts  Popcorn  Cereal bars  Crackers  Crunchy cereal e.g. Clusters  Crisps  Meat on the bone e.g. chicken drumstick Other (please describe)………………………………………………………………………………………………………………………………………………..

c. What do you usually drink in-between meals while wearing braces? (TICK AS MANY THAT YOU NEED TO)

 Water  Fresh fruit juice

 Flavoured water  Tea or coffee with sugar

 Fruit squash  Tea or coffee without sugar

 Fizzy drinks (e.g. Coke, Lucozade, lemonade)  Milk

 Flavoured milkshakes  Other………………………………………………………………………………………

d. What do you usually drink at meal times while wearing braces? (TICK AS MANY THAT YOU NEED TO)

 Water  Fresh fruit juice

 Flavoured water  Tea or coffee with sugar

 Fruit squash  Tea or coffee without sugar

 Fizzy drinks (Coke, Lucozade, lemonade)  Milk

 Flavoured milkshakes  Other……………………………………………………………………………….

Appendixe. What 1 happens if you eat or drink the wrong things while wearing a brace? (TICK AS MANY THAT YOU NEED TO)

 Nothing  Damage the teeth

f. Do Stain you the think teeth you have been given enough infoMakermation bad bugs/bacteria on eating in and the mouthdrinking while wearing a train-track brace?  Scar the teeth  Break or damage the brace  Yes  No  Cause tooth decay  Make brace treatment take longer g. How can we improve the information given to you about diet and what to eat and drink when Appendix Wear 1 away the teeth  Braces have to be taken off before teeth have been fully wearing a train-track brace? straightened

……………………………………………………………………………………………………………………………………………………………………………………………… Other (Please describe)……………………………………………………………………………………………………………………

……………………………………………………………………………………………………………………………………………………………………………………………… f. Do you think you have been given enough information on eating and drinking while wearing a ………………………………………………………………………………………………………………………………………………………………………………………………………train-track brace? 2

………………………………......  Yes  No ......

g. How can we improve the information given to you about diet and what to eat and drink when wearing a train-track brace? ………………………………………………………………………………………………………………………………………………………………………………………………TThhaannkk yyoouu ffoorr ffiilllliinngg tthhiiss iinn!! ……………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………………………… Please return this questionnaire to your orthodontist, reception or you can post it back to: ………………………………...... Miss S Stephens, Orthodontic department, Eastman Dental Hospital, 256 Grays Inn road WC1X 8LD

32 TThhaannkk yyoouu ffoorr ffiilllliinngg tthhiiss iinn!!

Please return this questionnaire to your orthodontist, reception or you can post it back to:

Miss S Stephens, Orthodontic department, Eastman Dental Hospital, 256 Grays Inn road WC1X 8LD

3

3

14 CLINICAL AUDIT OF PATIENT ORAL HYGIENE MEASURES R.M. Stephens, S.L. Stephens, S.J. Cunningham, F.S. Ryan Eastman Dental Hospital UCLH Foundation Trust and UCL Eastman Dental Institute INTRODUCTION After each question there was a list of responses and patients Orthodontic fixed appliances can encourage the accumulation were asked to tick all options that applied to them. Patients of plaque and bacteria and therefore a high standard of oral were also given the opportunity after each question to write health is important. Poor oral hygiene during fixed appliance additional information if their practice or views were not treatment increases the risk of dental caries and periodontal included. The questionnaire was then piloted on 5 patients to disease and may necessitate discontinuation of treatment1. assess acceptability and readability and any suggestions for Therefore, it is essential that the orthodontic team provides improvement were made. The Flesch Reading Ease test score oral hygiene instruction and guidance and should ensure that was 80 which is approximate to the reading age of an average patients are able to demonstrate appropriate levels of oral 10 year old4. hygiene before treatment commences. Research has shown that two thirds of orthodontic patients would like to know how fixed Sixty consecutive patients attending orthodontic appointments 2 appliance treatment may affect toothbrushing . As the majority for fixed appliance adjustment with orthodontic registrars/ of orthodontic patients are adolescents, providing information postgraduate students, over a two day period were asked to to both patient and parents can play a key role in maintaining complete a questionnaire. Patients included in the audit were 2 oral health . Lees and Rock (2000) compared the effectiveness those undergoing active orthodontic treatment with fixed of written information, a one to on session with a hygienist, and appliances for orthodontic or orthognathic treatment. There a videotape of oral hygiene instruction for patients who were was no age restriction and both adults and children/adolescents being treated with fixed appliances and found no significant were asked to complete the questionnaire. Patients excluded difference between three methods, indicating that no single from the audit were those who had not yet commenced 3 method suits all learners . orthodontic treatment, those in retention, those attending review appointments and those undergoing removable AIMS appliance treatment only. The aims of this audit were to: Patients were asked to complete the questionnaire at the end of 1. To assess patient oral hygiene practices whilst undergoing their appointment. The questionnaire was then returned by the fixed appliance treatment. patient to a data collection box at the reception desk in order to 2. To assess patient knowledge of the importance of oral maintain confidentiality and anonymity. hygiene whilst undergoing fixed appliance treatment. 3. To identify areas for which information provision could be improved. RESULTS Sixty questionnaires were distributed and fifty questionnaires DESIGN AND SETTING were returned giving a response of 83%. Sixty four percent This was a prospective questionnaire-based audit carried out of respondents were female and 36% were male. Forty two over a two week period in January 2012 in a postgraduate percent were aged between 15 and 18 years. The results from teaching hospital. the questionnaire are displayed in the tables below.

STANDARD Age Category 12-14 15-18 19-25 26 + years There were no set standards available in the literature. The years years years audit standards were set by the authors following discussions at Percentage 30 42 16 12 a departmental audit meeting prior to data collection: • 100% of patients should carry out suitable oral hygiene Table 1. Response to question: How old are you? practice. • 100% of patients should be aware of the consequences of Attendance for GDP check-ups Percentage inappropriate oral hygiene practices whilst wearing a fixed Every 3 months 4% appliance. • 80% of patients should feel they have been provided with Every 6 months 46% sufficient information about oral hygiene practices whilst Once a year 6% wearing a brace. When my orthodontist tells me to go 16% I don’t need to go 8% METHOD A questionnaire (appendix 1) on patient oral hygiene measure Other 6% was developed by the audit team. There were 8 questions in I do not have a GDP 2% total which were divided into three sections which included; Table 2: Response to question: How often do you see your 1. Patient demographics; age and gender. GDP for check-ups? 2. Dental appointments; how often patients see their general dental practitioner for routine check-up appointments. This Seen a hygienist Percentage section also asked if patients had seen a hygienist for oral Yes 64% hygiene advice and, if so, when during orthodontic treatment this occurred. No 36% 3. Cleaning teeth. This section asked patients how often they Table 3: Response to question: Have you seen a hygienist brushed their teeth and what they used to clean their teeth5. for tooth brushing advice? The last part of this section also asked patients what they thought would happen if they did not carry out the correct oral hygiene measures. 33 If seen a hygienist when was the visit Percentage DISCUSSION The results showed that not all patients see a general dental Seen hygienist before treatment 39% practitioner for regular check-ups despite nearly all patients Seen hygienist after treatment 36% being referred to the department by a general dentist or Seen hygienist before commencement 25% orthodontic specialist. Patients are required to be registered of treatment and after commencement of with a general dental practitioner before embarking upon treatment treatment within the department. Therefore, orthodontists Table 4: Response to question: If you have seen a hygienist need to ensure that all patients remain registered with a when was this? general dental practitioner and encourage their patients to attend for routine dental care whilst undergoing orthodontic Frequency of tooth brushing Percentage treatment. The level of plaque accumulation, gingival health Twice a day 80% and presence and sign of decalcification should be recorded Once a day 8% prior to commencing orthodontic treatment and also during treatment. If the level of oral hygiene or oral hygiene practice Every 2-3 days 4% is inadequate this should be communicated to the patients, the Other 8% patient’s parent (if under 16 years of age) and the patient’s Table 5: Response to question: How often do you brush general dental practitioner. your teeth? With regard to suitable oral hygiene practice, the audit standard Oral hygiene measure Percentage was not met because only eighty percent of patients brushed Normal toothbrush 74% their teeth at least twice a day and only a third carried out inter- Electric or battery toothbrush 24% dental cleaning. Patients should be encouraged to brush their Inter-dental brush 26% teeth at least twice a day and use inter-dental brushes dipped Single tufted brush 10% in fluoridated toothpaste to obtain high approximal fluoride 5 Mouthwash 36% concentration . Over a third of patients used a mouthwash but only sixteen percent reported using a fluoridated mouthwash. Fluoridated mouthwash 16% The use of a fluoridated mouthwash may significantly reduce Dental floss/tape 8% white spot lesions during orthodontic treatment6 therefore it is Disclosing tablets 8% beneficial to incorporate this as part of a routine oral hygiene Toothpick 6% regime. Super floss 4% Other 4% Not all patients were aware of the consequences of African tooth stick 0% inappropriate oral hygiene practices. Patients were more likely to associate bad breath with poor oral hygiene rather Table 6: Response to question: What do you usually use to than periodontal disease or white spot lesions. Therefore, clean your teeth whilst wearing train track braces? continued effective oral hygiene practice advice and reminders of the consequence of poor oral hygiene should be reinforced Consequence of poor oral hygiene Percentage during orthodontic treatment. Referring practitioners should be Tooth decay 86% advised to refer well motivated patients with good oral hygiene Bad breath 76% for new patient appointments. Dirty brace 76% Stained teeth 68% The majority of patients felt that they had been provided with Swollen gums that bleed 68% sufficient information about oral hygiene practice during fixed appliance treatment; and the audit standard was met for this Mark on teeth 60% aspect, however 12% of patients felt they had not been given Build up of bad bugs 36% the correct amount of information and a small number of Other 8% patients requested more written information on oral hygiene Nothing 2% practice. Ideally all patients should feel they have been Table 7: Response to question: What do you think happens provided with appropriate information. In this department, if you do not clean your teeth properly? oral hygiene instruction is supplemented with the appropriate information leaflets at the start of treatment. The extent of oral Correct amount of information on tooth Percentage hygiene reinforcement during treatment will depend upon the brushing individual patient. In order to enhance the effectiveness of Yes 88% this information clinicians should ensure that patients have No 12% received the information by more than one method. Clinicians should provide verbal instruction, ensure patients have read Table 8: Response to question: Do you feel you have been the relevant British Orthodontic Society information leaflets given enough information on how to clean your teeth whilst and also educate parents. Study models to demonstrate oral wearing a train track brace? hygiene practice and clinical photographs to demonstrate The last question gave patients the opportunity to make any the consequence of poor oral hygiene could be employed to additional comments. Only three patients made comments and educate patients and parents. Patients should be referred to the this included: School of Hygiene and Therapy at the Eastman Dental Hospital • “Provide information on websites to visit” for additional support if required. • “Provide information leaflets on what cleaning products to use” • “Give me a leaflet” 34 RECOMMENDATIONS REFERENCES 1. Ensure all patients are registered with a GDP before starting 1. Heintze S.D, Jost-Brinkmann P.G, Finke C, Miethke R.R. (1999) before starting treatment and reinforce the importance of Oral health for the orthodontic patient, P1-23, Quintessence regular check-ups. publishing Co, 295-8, Chicago, USA 2. Orthodontists should; 2. Stephens R.M, Ryan F.S, Cunningham S.J. (2013) Information seeking behaviour of adolescent orthodontic patients, American a. Continue to provide verbal reinforcement of oral hygiene Journal of Orthodontics and Dentofacial Orthopedics 143: 303-309 instruction during treatment and also reiterate the risks of 3. Lees and Rock (2000) A comparison between written, verbal and poor oral hygiene. videotape oral hygiene instruction for patients with fixed appliances b. Demonstrate oral hygiene practice on study models to 27: 323-327 patients and parents. 4. Flesch R (1948) A new readability yard stick. Journal of Applied c. Use visual information such as clinical photographs to Psychology 32: 221-233 demonstrate the consequences of inadequate oral hygiene 5. Särner B, Dirkhed D, Lingdtröm P (2008) Approximal fluoride practice could be employed to educate patients. concentration using different fluoridated concentration using different d. Ensure oral hygiene advice leaflets are easily accessible fluoridated products alone or in combination. Caries research 42: 73-78 to patients and parents. 6. Geiger AM, Gorelick L, Gwinnett AJ, Benson BJ (1992) Reducing e. Refer patients to the School of Hygiene and Therapy at white spot lesions in orthodontic populations with fluoride rinsing 10 the Eastman Dental Hospital for additional support if : 403-407 required.

Number…… QQuueessttiioonnnnaaiirree ffoorr ppaattiieennttss wweeaarriinngg ttrraaiinn--ttrraacckk bbrraacceess Please could you spend a few minutes of your time to fill in this questionnaire?

We are interested in finding out what you know about cleaning your teeth and what you eat whilst wearing a brace. This is so we can try and improve our patient care in the future.

SECTION 1: ABOUT YOU

a. Are you?

 Male  Female

b. How old are you?

…………………

SECTION 2: DENTAL APPOINTMENTS

a. How often do you see your general dental practitioner (own dentist)? (TICK ONE BOX ONLY)

 I don’t need to go anymore because I am seen here  Once a year

 When my orthodontist tells me to go  Every 6 months

 I don’t have one  Every 3 months

 Every 2 years  Other (tell us how often)………………………………………

b. Have you seen a hygienist for tooth brushing (TICK ONE BOX ONLY)

 Yes  No

c. If yes when did you see the hygienist? (TICK ONE BOX ONLY)

 Before I had my braces put on  After I had my braces put  Both before & after I had my braces put on on

35

1

SECTION 3: CLEANING YOUR TEETH

a. How often do you usually brush your teeth? (TICK ONE BOX ONLY)

 Once a day  Twice a day  Once every 2 or 3 days

 Less than once every 2 or 3  Other (please describe) …………………………………………………………………………… days

b. Do you usually brush your teeth before you see your orthodontist? (TICK ONE BOX ONLY)

 Yes  No

c. What do you usually use to clean your teeth? (TICK AS MANY OPTIONS AS YOU NEED TO)

 Toothbrush  Super‐floss

 Electric or battery toothbrush  Tooth pick

 African tooth stick  Disclosing tablets

 Single tufted brush  Mouthwash

 Interdental (TePe) brush  Fluoride mouth wash

 Dental floss/tape  Other (please describe)……………………………………………………………………………………

d. What do you think happens if you do not clean your teeth properly? (TICK AS MANY OPTIONS AS YOU NEED TO)

 Nothing  Build up of bad bugs

 Bad breath  Swollen gums

 Stained teeth  Bleeding gums

 Marks on the teeth  Gum disease

 Decay/rotting teeth  Damage to teeth and gums

 Dirty brace  Other (please describe) …………………………………………………………………………………………………

e. Do you feel you have been given enough information on how to clean your teeth whilst wearing a brace? (TICK ONE BOX ONLY)

 Yes  No

Thank you for filling this in!

Please return this questionnaire to your orthodontist, reception or you can post it back to: Miss Rachel Stephens, Orthodontic department, Eastman Dental Hospital, 256 Grays Inn road WC1X 8LD

2

36 15 Re-Audit of Orthodontic Model Boxes F. Ahmed, H. Mazey. University Dental Hospital Manchester INTRODUCTION METHOD Study models within orthodontics serve to aid diagnosis We identified 10 model boxes per clinician (consultants, and treatment planning1. Dental plaster casts have been FTTAs, specialty doctors, StRs, post-graduate students and considered the ‘gold standard’ due to their versatility, in orthodontic therapists), which were assessed for compliance ease of production, measurement recording, and ability to be to the standards from the model box storage rooms at UDHM. articulated1. Through the course of treatment study models All current clinicians’ were assessed in this audit. This are reference tools for assessing progress of treatment, e.g. provided a total of 220 model boxes. A data collection sheet arch form, arch width and inter-canine width. Study models was piloted on 10 model boxes, adapted as necessary and used aid learning and teaching, for registrars, therapists but also for to collect the data for each of the 220 model boxes assessed. peer review, and are a required part of compulsory assessments Data was collected in August 2013 and subsequently analysed in orthodontic primary care contracts2. Study models are via summery statistics. No methodological problems were also requirements for examination purposes at MOrth, It is a encountered. medico-legal requirement that study models are retained until patients reach the age of 25 for children or 8 years for adults3. RESULTS The retention of study models as patient records necessitates The majority of the clinicians in both cycles at UDMH are they are retained in their original form, without fractures or specialty registrars or postgraduate students at 59% in cycle 2 breaks. If models (study or working models) are not maintained and 81% in cycle 1. Table 1 indicates the type of clinician for there is a loss of clinical time chair side as well as a cost cycle 1 and 2. implication in their repair. Model boxes have the potential to Clinician Cycle 1 Cycle 2 harbour infective microorganisms due to their constituents StR/PG 81% 59% being mainly cardboard and foam4. It is essential only items Consultant 13% 18% free of potentially harmful microorganisms be kept within FTTA 6% 9% model boxes. Departmental policy from cross infection policy Therapist 0% 9% permits the retention of cold disinfected wax bites, foam and Specialty Doctor 0% 5% laboratory ticket within the model box, but no other items. Table 1: Type of Clinician in audit cycles 1 and 2 AIMS AND OBJECTIVES The aims and objectives of this audit were to: Standard 1 Labelling of Model boxes • Assess safety and storage of patient model boxes Only 17 % of model boxes were labelled correctly in cycle 2, • Provide information on contents of model boxes at the 100% of models were labelled correct in cycle 1, the details are University Dental Hospital Manchester presented in figure 1. 56% of model boxes had all the patient • Compare results to cycle 1 (2007) details present on the model boxes. The most common reason for incorrect labelling of patient details was the abbreviation STANDARDS of the patient’s first name (81%). The majority of model Currently no model box standards exist, the standards were boxes had patient’s hospital number (98%). 44% of model derived from departmental policy (relating to model box boxes contained the consultant’s number. Only 34% of model labelling only) and experienced consultants. The results boxes had the year of the initial model present. Nearly all from the 2007 audit (cycle 1) were used as standards for two model boxes had the clinician’s name present at 99%. 58% of outcomes (correct packaging and model boxed containing no model boxes had a sticker present indicating active, review or inappropriate items). Local cross infection policies were used discharged patient. The model box colour was correct for only to help derive standards. A target of 100% compliance was set 34% on the model boxes. for the agreed standards are listed below: 1. Correct labelling of model box, according to departmental policy: A. Patient details present on model box (full surname and first name) B. Hospital number C. Consultant number D. Consultant colour E. Year of initial models F. Clinician name G. Sticker indicating active (yellow), review (red) or Figure 1: Missing details of model boxes discharged (blue) patient Standards 2 – 8 model box contents 2. Correct packaging of models, defined as: foam present with 83% of model boxes in cycle 2 were packaged correctly; this dentition facing the foam and study models in chronological was lower than cycle 1 at 92.5%. The most common reasons order for packaging not being correct in cycle 2 was no foam being 3. Initial study models present in the model boxes and the teeth not facing the foam. 4. Last working model only (if applicable) 5. No sharp objects within the model boxes 98% of initial study models were present in the model boxes. 6. Laboratory ticket present 80% of model boxes contained the last working model only. 7. Cold sterilised wax bite 20% of model boxes contained other working models as well 8. No other items as the lost working model. As a total 40% of model boxes did not have a working model. 37 8% of the model boxes contained sharps in cycle 2, the most model. Historic working models are redundant and should be common sharp was arch wires. Other sharps that were present disposed of upon the fabrication of a new working model. were URAs and an expansion screw key. Laboratory tickets were present in 72% of model boxes. They 72% of lab tickets were present in model boxes in cycle 2. contain patient details which facilitate the formation of the initial model box. Wax bites were present in only 44% of 44% of model boxes contained wax bites in cycle 2. model boxes, retention of wax bites allows the models in static The most common ‘other item’ was the laboratory prescription, occlusion to be checked for accuracy and can facilitate the with 2% of model boxes containing them. Other items within fabrication of duplicate models. the boxes were overfilled models, models on top of foam, Sharps were present in 8% of model boxes. The most common special trays, clear bags, elastic bands, patient instruction cause was retention of arch wires (5% of model boxes). Arch sheets, post it notes and occlusion wax bites. wires should be disposed of after use and if required again In cycle 2 16% of model boxes contained inappropriate new wires should be sought. Expansion screw keys and items (including sharps), this is significantly less then cycle URA appliances were present in around 1% of model boxes. 1, in which it was found 92.5% of model boxes contained Expansion screws are used as part of removable or functional inappropriate items. appliances, however should be given to the patient and not stored in the model box. URAs should be disposed of as sharps Standard Compliance Compliance Change after their completion and not retained. Audit cycle 1 Audit cycle 2 The most common other item was the laboratory prescription 1. Correct labelling of model box 100% 17%  at 4%. Departmental policy requires laboratory prescriptions to 2. Correct packaging of models 92.5% 83%  be stored in the patient’s clinical notes. Clear bags and post-it 3. Initial study models present - 98% notes were kept in around 1% of model boxes. Other items 4. Last working model (if - 80% should not be kept in model boxes as they add disorganisation applicable) and clutter. 5. No sharp objects within the - 92% A previous re-audit showed 100% compliance to model box model boxes content standards at Birmingham Dental Hospital and Sollihull 6. Laboratory ticket present - 72% Hospital5. Standards were based on: no removal appliances, no 7. Cold sterilised wax bite - 44% exposed archwires (permitting sealed archwires), last working 8. No Inappropriate items 7.5% 84%  model only and laboratory prescriptions. Comparatively this (including sharps) re-audit at UDMH achieved 74% compliance, with more than Table 2: Results summary for audit cycle 2 and cycle 1 one last working model the greatest non-compliance to the standard. The re-audit found production of written guidelines DISCUSSION an effective method of improving compliance (93% cycle 1 – The clinician type from cycle 1 to cycle 2 is broadly the same, 100% cycle 2)5. however in cycle 2 a specialty doctor and two therapists have been introduced. Another published re-audit from 2010 showed 2 cycles of model box content audit4 from Dundee Dental Hospital. The results of this audit cycle fall significantly short of the Standards were: last working model only, no removal agreed target of 100% except for standard 3 regarding whether appliances, no miscellaneous items, no archwires, no wax bites, initial study models were present. no laboratory prescriptions. The compliance achieved from the Only 17% of model boxes were labelled correctly in cycle 2, re-audit at Dundee Dental Hospital was 65%, non compliance 100% of models were labelled correct in cycle 1. This could be was attributed to the retention of laboratory prescriptions and due to the change in departmental policy regarding labelling, wax bites. Comparatively the re-audit at UDMH achieved 54% requiring greater information. New required details such as compliance, however the standards at UDHM considered the consultant information and stickers (indicating activity) were retention of a wax bite instead of its absence being a standard. the most neglected details. Interestingly the authors considered items specific to risk infection (archwires, removal appliances or any other item Packaging of model boxes was compliant to a slightly lower deemed to carry an infection risk). Reduction in infection risk order than in cycle 1 (cycle 1-92%, cycle 2-83%). The main from cycle 1 (53.4%) to cycle 2 (1.2%) was 52.2%, the authors cause was absence of foam and teeth not facing the foam. Both attribute this reduction to departmental guidelines. of these errors in packaging model boxes can result in damage to models and affect clinicians’ use of the models. Packaging CONCLUSION of models relates to the initial packaging but also clinicians’ The key conclusions which can be drawn from this re-audit are: and members of staff’s use of the model box and repackaging. • None of the standards meet the 100% compliance target. Errors can occur at both points. Only one model box contained • Current overall departmental compliance with the correct models out of chronological order, this suggests a very high labelling of study models is poor, at 17%. compliance to ordering models in chronological order. • Sharp objects were found in 8% of model boxes, which could compromise clinician safety. Initial study models were present in most model boxes (98%). • Inappropriate items were found in 16% of model boxes, However in 5 model boxes no study models were present, they which is a significant improvement from cycle 1. contained only working models, this maybe due to the study models • Further education of the team is required to improve being in another box, or no study models having been taken. compliance, and implementation of any recommendations The last working models were present in 60%, of which the must be ensured. relevant last working model was present in 80% of model boxes. 20% of the model boxes contained an extra working 38 RECOMMENDATIONS REFERENCES The results of this audit were disseminated to staff at the local 1. Rheude B, Sadowsky PL, Ferriera A, Jacobson A (2005) An orthodontic clinical effectiveness meeting. Recommendations evaluation of the use of digital study models in orthodontic diagnosis included: and treatment planning. Angle Orthod 75: 300-4 • Education to staff regarding the standards for contents of 2. British Orthodontic Society [03/06/13]. Quality Assurance in NHS Primary Care Orthodontics. Available from: study model boxes. All staff in the department will be given http://www.bos.org.uk/researchaudit/theparindex/ a list of requirements for orthodontic study model boxes that QualityassuranceinNHSprimarycareorthodontics can be referred to when constructing a box for a new patient. 3. NHS Choices. How long should medical records (health records) • The formation of department policy on the labelling and be kept for? [27/05/2013]. Available from: http://www.nhs.uk/chq/ contents of study model boxes. This policy will be placed in pages/1889.aspx?categoryid=68&subcategoryid=160. the Orthodontic department in a readily viewable location as 4. Shaw K, McIntyre GT, Roud W (2010) An audit of Orthodontic this will consistently act as a reminder to department staff. model boxes at Dundee Dental Hospital: What’s in the Box? British • Re-audit in 12 months. Completion of the audit cycle will Orthodontic Society Clinical Effectiveness Bulletin 25: 14-15 indicate if any improvement in standards has been achieved. 5. Ullah R, Panesar J, Thind B (2014) Thinking Beyond The Box: An Audit of Orthodontic Model Boxes. British Orthodontic Society Clinical Effectiveness Bulletin 32 : 23-25

16 AN AUDIT OF INSTRUMENT DECONTAMINATION STANDARDS AND BARCODE STICKER USAGE IN A LONDON TEACHING HOSPITAL ORTHODONTIC DEPARTMENT L. Tabrett, H. Ling and P. Acharya. Eastman Dental Hospital, London INTRODUCTION was assessed in terms of fitness for purpose. Decontamination can be defined as ‘the combination of processes used to make reusable instruments safe for further Part 2: Use of Barcode Stickers use on patients and for handling by staff’.1 In 2003, the The second part of the audit was a retrospective assessment National Decontamination Strategy for Modernising the of 151 sets of notes with entries made in the orthodontic Provision of Decontamination Services (2003) proposed department. A data collection sheet was used to collect details a set of standards for all NHS facilities at every stage of of the grade of the clinician, the procedure carried out and the the decontamination cycle, including the provision of presence of an appropriately located sticker tracking the use decontamination areas away from the clinical environment of instruments during that treatment session. An equal spread and instrument tracking systems.1 Following the launch of of notes for all grades of clinician was assessed, with notes the National Decontamination Strategy, decontamination of being sampled from those pulled for patients to be treated reusable instruments within the Eastman Dental Hospital consecutively by each clinician during a one week period of (EDH) was centralised to the Central Sterile Service data collection. The results were analysed anonymously. Department (CSSD). The decontamination and use of RESULTS instruments is tracked throughout the decontamination cycle, Quality of Instrument Trays including the use of stickers in patient records. During the three week audit period, 341 instrument trays were AIMS recorded including 224 fixed appliance trays (71%) and 53 The aim of the present audit was to assess compliance with the removable appliance trays (17%). National Decontamination Strategy. Our specific aims were: Overall, the 100% gold standard was not achieved as 81% • To ensure the preparation of instrument trays was in line of instrument trays were of a satisfactory standard. 169 with recommended professional standards. fixed appliance trays (75%) and 49 removable appliance • To assess the usage of barcode stickers within patient trays (92%) were satisfactory. 100% of bond-up (n=27) and records in the orthodontic department for instrument debond trays (n=10) audited were satisfactory. The reasons tracking purposes. for unsatisfactory fixed and removable trays are displayed in STANDARDS Figure 1. The majority of ‘dirty’ fixed appliance instruments In a previous cycle of this audit within the orthodontic were due to a retained elastomeric module in the mosquito department at the EDH, a gold standard of 85% was set. forceps (n=4, 66% of all ‘dirty’ fixed appliance instruments). However, in accordance with a similar audit in the literature2 In other cases, no reason was given and this could have been we agreed upon a gold standard of 100%. Consequently, 100% due to the same reason, or rust associated with inadequate of instrument trays should be correctly prepared and 100% of oiling of the instruments. patient records should have an appropriately located sticker tracking instrument use. Removable (n=4) 25 25 50 Unoiled Removable (n=4) 25 25 50 DefecveUnoiled MATERIALS AND METHODS Dirty Defecve Part 1: Quality of Instrument Trays MissingDirt instrumenty This was a prospective audit of all instrument trays used in the Extra Missinginstrument instrument Type of tray Fixed (n=55) 22 44 11 13 55 orthodontic department over a three week period in February Extra instrument Type of tray Other 2013. A tick-box style data collection form was designed and Fixed (n=55) 22 44 11 13 55 Other completed by the clinician or nurse at the time of tray usage. Details recorded included the completeness of the tray and the 0% 20%40% 60%80% 100% 0% 20%40% 60%80% 100% cleanliness and quality of the instruments. Cleanliness was Percentage of unsasfactory trays (%) assessed in terms of visible contaminants, including adhesive, Figure 1. The reasonsPercentage for 55 of unsasfactory unsatisfactory trays (% )fixed appliance debris and retained elastomeric modules. Instrument quality and 4 unsatisfactory removable appliance trays. 39 After trays containing one or more defective instrument(s) had not be an accurate representation of instrument quality as been discounted, 89% of all instrument trays were deemed of only the instruments required during that particular treatment satisfactory standard. 24 fixed trays (11%) had a defective session were likely to have been assessed. In contrast, Dixon instrument. Mosquito forceps were the most frequently (2008)2 adopted a more standardised method in which every recorded faulty instrument (5% of all fixed trays). instrument on every tray was examined. The sharpness of ligature cutters was assessed on a tied 0.008” stainless steel Use of Barcode Stickers ligature on an appliance demonstration model and distal end Of the 151 sets of notes sampled, 54% (n=82) had an cutters used on a 0.019 x 0.025” SS wire. Likewise, the quality appropriately located sticker tracking the instruments used of the grip of the mosquito forceps was tested by tying a figure during the last treatment session in the orthodontic department. of eight module on a bracket on a model. However, Dixon2 The 100% gold standard was not achieved by any grade of had a more manageable sample size of 30 instrument trays clinician (see Figure 2). Stickers were used appropriately over a two week audit period. Application of a similar method for 54% of fixed appliance adjustment (n=59) and 77% of would not have been possible in a large orthodontic department removable appliance adjustment procedures (n=13). without compromising patient care. In addition, the 314 trays

80 assessed during our audit cycle only represented 32% of the ) total number of trays returned to CSSD from the orthodontic 70 department during the week audit period (972 trays). 60 50 Use of Barcode Stickers 40 The tracking of instruments was one of the key measures 30 proposed in the National Decontamination Strategy for 20 Modernising the Provision of Decontamination Services. In 10 the present cycle, only 54% of orthodontic patient records had 0 an appropriately located sticker tracking the use of instruments. Consultants Post-CCST StR1 StR2 StR3 Total This finding was likely to be the result of non-compliance with (11/16) (12/16) (19/37) (24/36) (16/36) (82/151) infection control protocols and also the ongoing problem of

Percentage of notes with scker present (% Grade of Clinician non-adhesive stickers being lost from the notes when they are Figure 2. Usage of stickers by clinicians in the orthodontic opened and used. department. (Figures in brackets represent the proportion The following recommendations have been made: of the total number of sets notes sampled with an • Clinical staff should work together to ensure the appropriate appropriately located sticker). use of stickers. Although nursing staff play an important DISCUSSION role in removing stickers from instruments wrapping, the The results of this audit have highlighted two areas for overall responsibility for placing stickers in notes remains improvement within the decontamination process at the EDH. with the treating clinician. 81% of the 314 instrument trays used in the orthodontic • Liaise with CSSD staff regarding quality of adhesiveness of department were satisfactory and 54% of the 151 patient barcode stickers. notes samples had an appropriately located sticker tracking • Re-audit in 2 years. instrument usage. Thus, the 100% gold standard was not CONCLUSION achieved for either part of the audit. A 100% standard of compliance relating to instrument processing Quality of Instrument Trays and tracking was not achieved in the present audit cycle. Regular Although the 100% gold standard was not achieved in the re-audit of our centralised decontamination system is essential to current audit cycle, comparison with previous cycles suggested ensure compliance with the National Decontamination Strategy improvements have been made. During a previous cycle and optimise the quality of patient care. conducted in 2010, 66% of 352 instrument trays audited during ACKNOWLEDGEMENTS a three week period were satisfactory compared with 81% of The authors would like to thank all clinical staff in the 314 trays in the present cycle. Moreover, 89% of instrument orthodontic department at the EDH for their co-operation trays were deemed satisfactory once those containing a during data collection. defective or faulty instrument had been discounted. The cost of replacing all faulty instruments may not be feasible in the REFERENCES current economic climate. However, there are a number of 1. Strategy for modernising the provision of decontamination services: changes in practice that would improve our compliance with NHS Estates; HMSO (2003). the National Decontamination Strategy for Modernising the 2. Dixon M (2008) Audit of the use and decontamination of Provision of Decontamination Services without increasing cost. instruments in a dental hospital orthodontic department. British Orthodontic Society Clinical Effectiveness Bulletin 21:22-24. The following recommendations have been made: • Improved communication between the staff in the orthodontic department and CSSD. • Staff in CSSD to ensure all instruments are appropriately cleaned and oiled during the decontamination process. • Repeat the audit with improved methodology and staff participation in 2 years. Two potential sources of error during this audit were identified; our method of assessing instrument quality and also compliance by staff in the department. Our results may 40 17 A re-audit of the use of fluoride mouthwash in orthodontic patients M Storey and L Mitchell. St Luke’s Hospital, Bradford Introduction advice and encouragement with regard to use The overall prevalence of demineralisation amongst • To attempt to assess compliance orthodontic patients has been reported as anywhere between • To implement changes and recommendations for re-audit in 2-96%1-4. This can be a significant clinical problem due to the two years poor appearance of the teeth that results and the potential for cavitation necessitating restoration. Standards Overall management is primarily preventive due to the • 100% are advised to use a daily fluoride mouthwash and are challenging nature of treating white spot lesions. Such given appropriate instructions regarding use, including the measures include careful initial patient selection, regular recommended frequency reinforcement of the importance of good oral hygiene and diet, • 95% use a fluoride mouthwash and the application of appropriate preventive medicaments, • 95% use it daily with good compliance being essential for success5. • 95% receive additional encouragement by orthodontic staff Fluoride is important in the prevention of decalcification. The 95% compliance targets were set following discussion with Marinho found a definite reduction in caries in children and departmental Consultants and were considered achievable. adolescents who regularly rinsed with a fluoride mouthwash6, whilst Geiger reported a 30% reduction in the incidence of Materials AND Methods decalcification when orthodontic patients used a fluoride The audit was commenced on 1st July 2013. All patients mouthwash7. attending orthodontic appointments at St Luke’s Hospital, Bradford for fixed appliance treatment were invited to participate A 2008 Cochrane review concluded that there was some anonymously. Data was collected until 100 questionnaires had evidence that regular rinsing with a fluoride mouthwash is been completed. effective at reducing the severity of white spots in orthodontic Data was collected by a specially designed, anonymous patients, and recommended daily rinsing with 0.05% NaF questionnaire answered by way of a series of tick boxes. The 7 8 mouthwash . Consequently, many orthodontists recommend questions were designed to investigate the current use of, and the use of a daily fluoride mouthwash throughout treatment to level of knowledge regarding, fluoride mouthwash in patients prevent demineralisation. undergoing fixed appliance treatment. A fluoride mouthwash is most effective if it is used regularly Patients were given the questionnaire to complete at the end of by the patient and therefore relies on patient compliance to their treatment session and instructed to place the completed succeed. There is evidence to suggest that compliance with questionnaire in a tray at reception. To avoid patients completing mouth rinsing is poor. Geiger reported that only 42% of more than one questionnaire, an identifying number was placed patients rinsed with a sodium fluoride mouthwash at least every at the top of each questionnaire. Data from the 100 completed other day, and those with the least compliance experienced questionnaires was entered into SPSS version 20 for analysis. greater decalcification7. In line with these recommendations, a 100ml bottle of 2% NaF Results mouthwash used to be dispensed to all patients undergoing 100 questionnaires were analysed. Not every patient answered fixed appliance treatment, with instructions on dilution to all the questions on the form, giving a response rate of between 0.05%. A departmental audit in 2007 found that 91.7% of 93 and 100%. respondents claimed to use their fluoride mouthwash, with Question 1: I was advised to use a fluoride mouthwash 76.7% claiming to use it daily. Only 67% of respondents felt when my braces were fitted that they were encouraged in its use by the orthodontic team 83% of respondents agreed that they were advised to use and only 60% felt that they had received warnings about a fluoride mouthwash when their braces were fitted, 5% accidental overdose9. disagreed, and 11% did not know (Chart 1). Recommendations following this audit included: 1. Written and verbal information regarding fluoride mouthwash when fixed appliances are placed, including information about dosage, overdose and misuse 2. Encouragement at each appointment 3. Reinforcement regarding use and safety by nursing staff 4. Waiting room information on the use and safety of fluoride mouthwash Unfortunately, the Trust’s pharmacy subsequently ceased dispensing fluoride mouthwash. Instead, patients are now advised to buy a proprietary 0.05% NaF mouthwash and are given verbal advice on its correct use. Aims Chart 1: Proportion of respondents who recalled being • To assess the proportion of patients using fluoride advised to use a fluoride mouthwash at placement of their mouthwash fixed appliances • To assess whether patients know how frequently they should Question 2: I use a fluoride mouthwash use fluoride mouthwash 80% of respondents stated that they use a fluoride mouthwash, • To assess whether patients feel they have had appropriate 18% did not, and 2% did not know (Chart 2).

41 68% of respondents stated that they received instructions about the use of fluoride mouthwash from the orthodontist, 5% from the nurse, and 10% from both the orthodontist and the nurse (83% in total received instruction). 16% stated that they had not received instructions (Chart 5).

Chart 2: Proportion of respondents who stated that they used a fluoride mouthwash

Question 3: I received instructions about how I should use Chart 5: Proportion of respondents who stated they received the mouthwash instructions from various members of the orthodontic staff 69% of respondents agreed that they had received instructions on the use of fluoride mouthwash, 13% disagreed, and 17% did Question 7: I was encouraged to use a fluoride mouthwash not know (Chart 3). by the orthodontic staff 76% of respondents agreed that they were encouraged to use a fluoride mouthwash by the orthodontic staff, with only 8% disagreeing (Chart 6).

Chart 3: Proportion of patients who recalled receiving instructions about fluoride mouthwash

Question 4: I use a fluoride mouthwash(frequency) Chart 6: Proportion of respondents who stated that they 64% used a fluoride mouthwash at least once daily. were encouraged to use a fluoride mouthwash 34% of respondents stated that they used a fluoride mouthwash Discussion twice daily, 30% used it once daily, 12% used it every other Disappointingly, none of the standards were met. day, 14% less than every other day, and 8% did not know. When the audits in 2000 and 2007 were conducted patients were given a dilutable mouthrinse free of charge with dosage Question 5: I think I should use a fluoride mouthwash instructions printed on the bottle This may have increased 55% of respondents thought that they should be using a awareness of the importance of its use as well as making the fluoride mouthwash twice daily, 29% thought once daily, 4% fluoride mouthwash more accessible. Compared with these every other day, and 5% did not know (Chart 4). previous audits there has been a reduction in the proportion of patients who reported using a daily fluoride mouthwash. This was particularly evident since 2007. A possible explanation for this might be that, patients now need to seek and, perhaps more importantly, pay for the mouthrinse.

Disappointingly, despite 83% of respondents stating that they had been advised to use a fluoride mouthwash, only 64% of respondents actually used a fluoride mouthwash at least once a day. Previous studies have also identified compliance in self- administered fluoride programs to be a significant problem7,10. Only 29% of respondents could accurately recall how often they should be using a mouthwash. 55% of respondents stated that they thought that fluoride mouthwash should ideally Chart 4: Actual and perceived frequency of use of fluoride be used twice daily. One explanation for this could be that mouthwash these respondents were unaware of the correct protocol but were aware that they should brush their teeth twice daily, Question 6: I received instructions from therefore incorrectly guessed that the mouth washing regime 42 would be the same. A further, more concerning, explanation regard to this sample, some patients might have attended a could be the consequence of conflicting advice. In line nurse-led clinic prior to the placement of fixed appliances. This with the current best evidence8 a 0.05% NaF mouthwash is is at the discretion of the orthodontist/therapist and may be a recommended by the Orthodontic Department for use once- further source of bias. daily, ideally at a different time to toothbrushing, to reduce the severity of white spots lesions. However, the instructions Conclusions and recommendations on several different brands of commercially available fluoride • Clear written instructions regarding the use and importance mouthwash advise twice-daily use, after brushing (Table of fluoride mouthwash with graphic demonstration of good 1). Only the recommendations/directions on the bottle of oral hygiene procedures and photographs of white spot Colgate Fluoriguard mouthwash were in line with the current lesions should be given to all patients when fixed appliances recommendations. As the Department does not currently are placed in addition to the existing verbal advice. provide written instruction regarding the use of fluoride • Re-instate nurse led clinics for all patients prior to treatment. mouthwash it is not surprising that patients may get confused. Emphasis should be placed on the importance of daily fluoride mouthwash use at this clinic. Mouthwash Dosage Instructions • Encouragement should be given to the patient throughout Aquafresh Extra Care 250ppm 10mls twice daily the duration of their treatment with regards to fluoride Sodium after brushing mouthwash use. Fluoride • Nursing staff should be encouraged to reinforce the information given by the orthodontist. Colgate Fluoriguard 0.05% Sodium 5-10mls once daily Daily Mouthwash Fluoride at a different time The recommendations will be implemented and re-audit within 225ppm to brushing two years. Dentyl Active Intense 0.05% Sodium ½ cap twice daily ACKNOWLEDGEMENTS Fluoride after brushing I would like to thank all the staff in the orthodontic department 225ppm for their invaluable help in distributing the questionnaires. Endekay Daily 0.05% Sodium ½ cap Fluoride Mouthwash Fluoride References 225ppm 1. Gorelick L, Geiger AM, Gwinnett AJ (1982) Incidence of white spot formation after bonding and banding. Am J Orthod 81: 93-98 Listerine Advanced 450ppm 15mls twice daily 2. Mizrahi E (1982) Enamel demineralisation following orthodontic Care Sodium after brushing or treatment. Am J Orthod 82: 62-67 Fluoride as directed by a 3. Ogaard B, Rolla G, Arends J, ten Cate JM (1988) Orthodontic dental professional appliances and demineralisation. Part 2. Prevention and treatment of Listerine Teeth and 100ppm 20mls twice daily lesions. Am J Orthod Dentofacial Orthop 94: 123-128 Gum Defence Sodium after brushing 4. Mitchell L (1992) Decalcification during orthodontic treatment with Fluoride fixed appliances – an overview. Br J Orthod 19: 199-205 5. Sudjalim TR, Woods MG, Manton DJ (2006) Prevention of Listerine Total Care 100ppm 20mls twice daily white spot lesions in orthodontic practice: a contemporary review. Sodium after brushing Australian Dental Journal 51: 284-289 Fluoride 6. Marinho VCC, Higgins JPT, Logan S, Sheiham A (2003) Fluoride Morrisons 6-in-1 Total 0.05% Sodium ½ cap twice daily mouthrinses for preventing dental caries in children and adolescents. Care Power Mint Fluoride after brushing Cochrane Database of Systematic Reviews Issue 3 : CD002284. DOI: Mouthwash 225ppm 10.1002/14651858.CD002284 Morrisons Cool Mint 0.05% Sodium ½ cap twice daily 7. Geiger AM, Gorelick L, Gwinnett AJ, Benson BJ (1992) Reducing Mouthwash Fluoride after brushing white spot lesions in orthodontic populations with fluoride rinsing.Am 225ppm J Orthod Dentofacial Orthop 101: 403-407 8. Benson PE, Parkin N, Millett DT, Dyer FE, Vine S, Shah A (2008) Tesco Everyday Value 0.05% Sodium 1 cap twice daily Fluorides for the prevention of white spot lesions during fixed brace Mouthwash Fluoride treatment. Cochrane Database of Systematic Reviews Issue 4: 225ppm CD003809. DOI: 10.1002/14651858. CD003809.pub2. Tesco Freshmint 0.05% Sodium 1 cap throughout 9. Shelton A (2009) A re-audit of the use of fluoride mouthwash Mouthwash Fluoride the day as in orthodontic patients. British Orthodontic Society Clinical 225ppm required Effectiveness Bulletin 22: 20-21 10. Geiger AM, Gorelick L, Gwinnett AJ, Griswold PG (1988) Wisdom Fresh Effect 0.05% Sodium 1 cap twice daily The effect of a fluoride program on white spot formation during Fluoride after brushing orthodontic treatment. Am J Orthod Dentofacial Orthop 1988 93: 225ppm 29-37 Table 1: Comparison of fluoride content and directions for use for different fluoride-containing mouthwashes Depending on how the question was phrased, between 69-83% respondents stated that they had received instructions regarding the use of mouthwash. The accuracy of these results is reliant on patient memory and honesty and is a potential source of bias. Although the orthodontist/therapist has the prime responsibility for giving information to the patient it was disappointing to find that only 15% patients recalled receiving information from the nursing staff (5% nurses alone, 10% from both). With

43 18 A General Practice Based Audit of Orthodontic Extraction Letters J McGarry. McGarry’s Dental Practice, Lisnaskea, Co.Fermanagh, N.Ireland Introduction carried out on a concurrent basis. We received orthodontic Orthodontists routinely request that general practitioners extraction requests for both adults and children though extract one or more teeth as part of a patient’s overall overwhelmingly the requests are for younger patients. A pro orthodontic treatment plan. Often these teeth are caries free, forma was drawn up with each of the six standards to be in an otherwise healthy dentition, with very little restorative completed with either a Y for Yes or an N for No. The dentist treatment having been carried out on the younger patients. filled out the pro forma at the time of the extractions. The These extractions are often a child’s first introduction to local date and the extractions carried out were noted on the pro anesthetic and can often cause high stress for the patients, forma with a box for free text comments, if the dentist felt parents and dentist alike. appropriate. In 2013 the DDU reported a three-fold increase in extraction Results error complaints from 2006 to 20111. In the past the quality 40 pro forma sheets were completed with 54 teeth extracted of the orthodontist’s extraction letter has been scrutinized, not only as the source of the error, but also as the means by which Standards for orthodontic extractions Number % of errors can be prevented2. However, the most common error of Yes total reported was that the dentist had misread the extraction letter1 Was the letter requesting extraction available in 38 95% and therefore it must be appreciated that mistakes resulting in advance of the extraction appointment? erroneous extractions can occur at a number of stages along the Was the notation of teeth to be extracted 32 80% process. communicated by the orthodontist in two forms? Locally this issue has been raised due to a number of incidents Was the extraction pattern requested in typed form 36 90% involving the extraction of the incorrect teeth. As a result of rather than written? these incidents a letter was sent by the Consultant orthodontist Was the letter requesting extractions available chair- 40 100% in the area to all referring orthodontists and general dental side at the time of extractions? practitioners, highlighting these errors and suggesting Was a DCP available chair side at the time of 40 100% recommendations and standards to prevent them. extraction to help identify the teeth to be extracted? The unfortunate implications of incorrect orthodontic Were the teeth noted on the letter struck through 40 100% extractions can be numerous but will often result in a with a pen and dated after the extractions? compromised treatment plan and the possibility of litigation. Table 2. Results Aims This is a General Practice based audit to assess the compliance Discussion with the standards set out by our Consultant for orthodontic The results of this audit fall short of the 100% compliance extraction letters received in my General Dental Practice (Table with the standards set. In such high risk extractions there is no 1) and to identify areas of improvement to ensure appropriate margin for error. Overall the compliance with recommendations extractions for orthodontic purposes. was 94%. We also have to highlight that as the practitioners we were also the subject and were “self-marking” ourselves for Standards for referring practitioners some of the audit. Given the prospective nature of the audit the 1. The letter requesting the extraction should be available in advance results of that part of the audit may be skewed. of the extraction appointment The main problem highlighted however by this audit is that the 2. The notation of the teeth to be extracted should be communicated in tooth notation is not communicated in two forms in every letter, two forms, both written and dental notation with 20% failing to meet this particular standard. The BOS Advice Sheet 12: “Orthodontic Extractions Risk Management 3. The extractions requested should be in typed form rather than Guidelines”3 recommends this as part of their overall hand-written gold standard for writing an orthodontic extraction letter. Standards for GDP at extraction appointment Completion of this audit has made it apparent that there is great 1. The letter requesting extractions is available chair-side at the time of variation between orthodontists (and even sometimes by the the extractions same orthodontist) as to how the information within extraction 2. A DCP is available chair-side at the time of extraction to help identify letters is presented. There must be uniformity in this regard in the teeth to be extracted that the teeth to be extracted are noted in two forms, typed and in dental notation, especially as practitioners vary as to their 3. The teeth noted on the letter struck through with a pen and dated 4 after the extractions preferred notation, commonly FDI or the Palmer Notation in the UK. (Another way of notating commonly used is “UR4” or Table 1. Standards “LL5”.) Method This was a prospective questionnaire-based audit carried out Another issue is the delay in the extraction letter being between January and October 2013 by two General Dental received at the practice. In this audit 5% were not available in Practitioners (J.M. and J.H). Patients included in the audit advance of the extraction appointment. This led to increased were those undergoing active treatment with a number of administration for the practice to ensure all letters were local Orthodontists. There was no age restriction or exclusion available at the extraction appointment. It has been known criteria and the patients selected were those that were attending for practitioners to phone the orthodontist, or more likely the the practice for an orthodontic extraction only. The audit was receptionists, to convey the information so that the dentist can

44 continue to extract the tooth. There is so much that can go orthodontists and GDPs. Tooth notation is not always conveyed wrong in a case such as this. This situation could be improved in two forms and this should be standardized. Teeth should by the use of digital correspondence between the practices, never be extracted without the written letter at the chair-side at especially given that there can be delays in getting letters the time of extraction. out of hospital departments and practices, and there are often We have found the standards very useful in our daily practice, increasingly delays with the postal service. Added to this is the especially annotating the extraction letter after extraction, a pressure to use cheaper services in the NHS e.g second class convenient method of communicating to other GDPs within post or even TNT instead of first class post. the practice which extractions have been completed. This of course is only effective when GDPs comply with the standard Our practice policy is to not extract any tooth without the letter requesting they have the extraction letter available at the time at chair-side. Patients have been refused extractions on this of extraction basis, hence the 100% compliance with this standard. When the standards were issued we made it practice policy to comply with Recommendations the Consultant Orthodontist’s standards. Therefore a pleasing We have communicated our findings with our local consultant, result is that we have complied in 100% of cases audited. In one who plans to re-draft a letter to all general practitioners and of the letters requesting extractions, the orthodontist gave us orthodontists. It will include an accompanying wall notice a choice of tooth to extract depending on which tooth had the as an easy reminder to help ensure that these guidelines are worst prognosis. Consideration must be given to the orthodontic strictly adhered to. We also recommend referring orthodontists treatment plan as this may alter very slightly depending on the share relevant radiographs and/or photographs, where possible tooth extracted. Such that were the second premolar extracted the to assist communication to GDPs. We plan to re-audit, and anchorage may need to be reinforced, however it may not should intend to invite neighbouring practices to participate, to give a the first premolar be extracted. Further information would be more representative conclusion. beneficial in this case. In certain circumstances it may be prudent for the orthodontist References to send a copy of an OPT if one has been taken. These can be 1. DDU HYPERLINK “http://www.theddu.com/press-centre/press- scanned onto paper or sent electronically and can be of great help releases/rise-in-extraction-error-claims-reports-ddu” http://www. especially if a lower third molar has to be removed. One local theddu.com/press-centre/press-releases/rise-in-extraction-error- orthodontist includes a scanned OPT with every letter requesting claims-reports-ddu (accessed 15/02/2014) extractions and also highlights the teeth to be removed on the 2. Benson PE, Walker MR, Harrison JE (2009) Regional audit of scanned copy along with two forms of notation. extraction letters: do we comply with BOS guidelines? The British Orthodontic Society Clinical Effectiveness Bulletin 22: 22-23 3.Development and Standards Committee of the British Orthodontic Conclusions Society (2001) Orthodontic Extractions Risk Management Guidelines– Compliance in general is very high with regards to the Advice Sheet 12. standards that were drawn up, but our small audit identifies 4. Harris EF (2005) Tooth-Coding Systems in the Clinical Dental that there are gaps in the information being conveyed between Setting”. Dental Anthropology 18 : 44. ISSN 1096-9411

19 AN AUDIT ON PATIENT SATISFACTION AMONG LINGUAL ORTHODONTIC PATIENTS R. Paul Cheruvathur, H. Patel. The Liverpool Brace Place, Liverpool INTRODUCTION 4. To identify the common difficulties for patients during the Recent years have seen a marked rise in adult patients treatment and the duration of those impairments. undergoing fixed orthodontic therapy and they are often less willing to accept conventional fixed orthodontic appliances. STANDARD Most of these adult patients want to achieve their desired result There are no previously defined standards specifically for without being shown in public that they are undergoing a patient satisfaction with their choice of lingual appliance. Since fixed orthodontic treatment. Lingual braces play an important all the suitable patients were given other appliance options and role in the armamentarium of specialist orthodontists in their alternatives during initial assessment, including conventional pursuit to meet these challenging patient expectations. Lingual metal braces, ceramic braces and InvisalignTM; the overall orthodontic appliances have markedly evolved over the past patient satisfaction with the choice of lingual brace appliance decade. In this audit we examine whether a lingual brace was set as 100%. system –IncognitoTM- is meeting those expectations and is there anything we can do to further improve the patient satisfaction. METHOD We also examine the extent of other well-documented reasons The setting of the audit is in a specialist referral orthodontic of discomfort among lingual appliance patients including practice. The audit was conducted between 1 January 2013 and speech and eating difficulty in this group. 31st December 2013. All patients who are undergoing or have completed fixed lingual appliance orthodontic treatment during AIMS 2012 and 2013 under the supervision of a single practitioner 1. The primary aim of the audit is to determine whether patients in a specialist orthodontic practice were given a questionnaire. are satisfied with their choice of appliance. Patients who had lingual braces for less than 4 months were 2. Identify the patient characteristics and motivating factors for excluded. Data was entered into a Microsoft Excel spread sheet choosing the lingual brace. and the results analysed. 3. To check whether those motivating factors/expectations are met by the choice of appliance. 45 RESULTS 30 patients met the selection criteria and were included in the audit of which 20 (66.7%) were female and 10 (33.3%) were male. The age distribution of the sample is shown in Figure 1. Although most patients where in 18-30 year age group (50%), you will notice nearly 23.33% (n=7) is above 40 age group. Among all the patients in this audit, 36.7% (n=11) had previous history of orthodontic treatment. Various options considered by patients before choosing a lingual brace were as follows: 70.0% ( n=21) considered clear aligners, 20.0% ( n=6) considered metal braces and 10.0% (n=3) considered ceramic braces.

Figure 3: Single most difficulty encountered during treatment After fitting the lingual braces, the speech difficulty lasted 1-2 weeks for 46.7% ( n=14) of patients. 40.0% (n= 12) reported speech difficulty for 2-4 weeks and 10.0% (n= 3) felt it for 4-8 weeks. Only 3.3% (n=1) reported speech difficulty lasted over 8 weeks as shown in Figure 4.

Figure 1: Age distribution Reasons for choosing lingual appliance are shown in Figure 2. 70.0% (n=21) chose lingual appliance because they did not want people to know they were wearing a brace.13.3% (n= 4) chose to get better results and 13.3% (n= 4) chose because they were embarrassed to have ‘train track braces’. Interestingly only one patient (3.3%) has mentioned ‘no risk of decalcification of front surface’ as a single important factor in Figure 4: Duration of speech difficulty after appliance fit their decision to choose a lingual brace. We also looked into the comfort of lingual appliance in the first month and after the first month. (Rate of comfort =1 being least comfortable and 10 being most comfortable). In the first month after fitting lingual braces, 66.7% (n=20) patients rated comfort between 4-7, 16.7% (n=5) between 8-10 and 16.7% (n=5) rated between 1-3. After the first month, the rate of comfort improved with 66.7% rating between 8-10, 30% (n=9) rating between 4-7 and only 1 patient (3.3%) rated between 1-4. 83.3% (n=25) mentioned people ‘never’ identified them wearing lingual brace. 16.7% (n=5) mentioned people ‘rarely’ identified them wearing lingual brace as shown in Figure 5. None of them mentioned ‘often’ or ‘very often’.

Figure 2: Reasons for choosing lingual brace treatment

The greatest single difficulty encountered during the treatment was reported as speech by 43.3% (n=13) of patients. This was followed by eating difficulty reported by 33.3 % (n=10), cleaning by 13.3% (n=4), irritation to gums reported by 6.7% (n=2) and 3.3% (n=1) patient reported pain from teeth. See Figure 3. Soreness on tongue was not mentioned in the questionnaire but was commented on by some patients.

Figure 5: How often others identify the lingual brace 46 Overall 86.7% (n=26) were ‘very pleased’ and 13.3% (n= 4) RECOMMENDATIONS were ‘pleased’ with the choice of appliance. No one mentioned 1. Detailed briefing of all patients on the possible duration ‘ok’ or ‘unhappy’. 100% satisfaction achieved for choosing and scope of potential difficulties the patient should expect lingual appliance as their appliance of choice for fixed should be undertaken prior to treatment being started with orthodontic therapy thereby meeting the audit standards. a fixed lingual appliance. This procedure will protect both the patient and orthodontist from unrealistic expectations or 5 90% (n=27) reported that they would recommend lingual disappointments . appliance treatment to others considering fixed orthodontic 2. Designing a leaflet with post-op instructions based on 1,6,7,8,9 therapy. 10% (n=3) were unsure and no one reported they available evidence to improve expectations and would not recommend lingual appliance treatment. comfort for lingual appliance patients. 3. Re audit in 12 months time after implementing the DISCUSSION recommendations. The patient characteristics were predominantly female (66.7%) and 18-40 age group (70%). There were only two patients ACKNOWLEDGEMENTS below 18 years. This could be because lingual appliance Many thanks to Joanne Gorton (practice manager) in collecting treatment is provided privately and patients below 18 years of the questionnaire, and Orthodontic Therapists Kate, Samantha age can receive free treatment under NHS funding if they are and Amy, The Liverpool Brace Place, Liverpool. eligible. It could also be due to conventional ‘train track braces’ being more socially acceptable among teenagers. REFERENCES The motivating factor is predominantly aesthetics with 83.3% 1.Caniklioglu C, Ozturk Y (2005) Patient Discomfort: A comparison either not wanting people to know they are wearing a brace or between Lingual and Labial fixed appliances. Angle Orthodontist 75: embarrassed to have ‘train track braces’. Speech and eating 86-91 difficulty constituted 76.6% of the single most difficult item 2. Fritz U, Diedrich P, Wiechmann D (2001) Lingual Technique – encountered during treatment. We have not looked specifically Patients’ characteristics, motivation and acceptance. J Orofac Orthop into impact of ‘soreness of tongue’ in this audit. The audit 63: 227-33. 3. Khattab TZ, Farah H, Al-Sabbagh R, Hajeer MY, Haj-Hamed Y findings are consistent with other retrospective surveys, which (2013) Speech performance and oral impairments with lingual and suggested that the patient’s discomfort with lingual brackets labial orthodontic appliances in the first stage of fixed treatment. A tends to disappear gradually within one month of starting randomized controlled trail. Angle Orthodontist 83: 519-26 treatment1,2. Speech was the most severe problem in patients 4. Stamm T, Hohoff A, Ehmer U (2005) A subjective comparison treated with lingual appliances1. There are various published of two lingual bracket systems . European Journal of Orthodontics research on discomfort associated with lingual appliances 27:420- 426 but the results can vary based on type of brackets used, types 5. Hohoff A, Fillion D, Stamm T, Goder G, Sauerland C, Ehmer U of questions asked and assessment times3. Literature shows (2003) Oral comfort, Function and hygiene in patients with lingual customised brackets (as used in this audit – IncognitoTM) with brackets. J Orofac Orthop 64: 359-71 6. Sinclair PM, Cannito MF, Goates LJ, Solomos LF, Alexander CM smaller dimensions result in significantly less impairment, (1986) Patient responses to lingual applainces. J Clin Orthod 20: 4 thereby enhanced patient comfort in lingual orthodontics . 396-404 Fritz has reported 87% would recommend the lingual technique 7. Fillion D (1997) Improving patient comfort with lingual brackets. J without reserve to relatives and friends2. This is consistent with Clin Orthod 31:689-694. our audit findings (90%). 8. Wiechmann D, Gerb J, Stamm T, Hohoff A (2008) Prediction of oral discomfort and dysfunction in lingual orthodontics: A preliminary CONCLUSIONS report. Am J Orthod Dentofacial Orthop 133:359-364 100% of patients were very pleased or pleased with the 9. Miyawaki S, Yasuhara M, Koh Y (1999). Discomfort caused by choice of lingual brace. The set standard was met in this audit bonded lingual orthodontic appliances in adult patients as examined although we should explore ways to improve patient comfort by retrospective questionnaire. Am J Orthod Dentofacial Orthop 115:83-88 during the first few weeks of treatment. The motivating factor is predominantly aesthetics with patients not wanting others to know they wear a brace. 83.3% were ‘never’ identified as wearing a lingual brace and 16.7% were ‘rarely’ identified as wearing a lingual brace. The common difficulties identified include speech, eating and keeping appliances clean. Speech difficulty did not extend beyond 4 weeks for 86% of patients. This information can be used to tailor the advice to lingual appliance patients in future.

47 Guidance for prospective authors The CE Bulletin is a peer reviewed publication with referees drawn from the FTTA members of the TGG. The referees’ reports are fed back to authors and utilised by the editors to recommend amendments as well as decide upon inclusion.

1) Document submission • Articles are best by email attachment to the Editor of CEB. • A covering letter should accompany each submission stating the names and addresses of all authors.

2) Document format. Tables and graphs must be formatted accordingly. • Manuscripts texts will only be accepted in Word format. • A separate Excel spread sheet file is required for any included graphs and charts.

3) Headings template. Audit project submissions will be expected to broadly follow a format as follows: • TITLE. This should be a succinct and accurate reflection of the project. • INTRODUCTION. To include rationale or need to undertake the project. • AIMS. A clear list of the project aims. • STANDARD(S). Should be quoted if available. • PROCESS/MATERIALS & METHODS. A clear explanation of the audit process. • RESULTS. Text should avoid simply repeating findings shown by graphs/charts. Clarification or explanation can be given if necessary. • DISCUSSION. As appropriate. • CONCLUSION/PLAN. The authors’ plans for implementation of findings to change practice as necessary, or to audit further should be described. • Acknowledgements. • References. Authors (Year) Title in full. J standard abbrev Vol No: Pages.

4) Graphs and charts, if included should be in Excel and • Have a concise accompanying legend. E.g. Figure 1. Result of treatment • The legend should be included in the main text rather than in the figure itself and should be in bold. • For the purposes of publication, graphs should be limited to 2 to 3 per submission. • Their content should not be overly complex, and be quickly and easily understood.

5) Tables should also be in Word format and similar recommendations apply. • Have a concise accompanying legend. E.g. Table 1. Number of appliances. • Limited to 10 – 15 rows to fit comfortably on the page.

6) References. Authors are responsible for accuracy and appropriateness. Their format is all italicised, no bold required. References are not compulsory but should be used if appropriate. Any references must be numerically referenced from the text in superscript. e.g.1 1. Smith J, Brown A (2005) Results of superb treatment. J Orthodont Surg 59: 103-6

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