RIGA STRADIŅŠ UNIVERSITY

Andra Liepa

Assessmentof orthodontic treatment

need and effectiveness

(speciality - orthodontics)

Summary of promotion paper

Research superviser Ilga Urtane, Dr.med.sc, professor

Riga 2004

Euro-Qual project support the presumption that there is a need for scientific

studies about orthodontic treatment need and quality of service according to a

common European framework. Orthodontic malocclusion or dentofacial

abnormality ranges from minor malalignment of the teeth to major facial

deformities. Between these extremes is a continuum of abnormalities that vary in

severity.

Angles classification (1899) and Andrews (1972) six keys of occlusion have been

the most commonly used methods for registration of malocclusion. They have,

however, certain shortcomings as a method by which to categorize the variety of

occlusal pattern. For instance, they take into consideration only morphological

deviations, although maiocclusion may involve deviation from aesthetically

levels of different severity. To overcome the difficulty of making reliable

assessments of occlusal features several methods, indices of occlusion have been

devised. An occlusal index may be used to record the severity of malocclusion,

orthodontic treatment need and treatment result in a mathematical form or

categorical form.

In orthodontic literature there are different indices used in different studies over

time since 60 and 70ties.

In late 80ties Shaw and Brook introduced the Index of Orthodontic Treatment

Need (IOTN). Recently Richmond and Daniels have developed The Index of

Complexity, Outcome and Need, which can be used both for the assessment of

orthodontic treatment need and for the evaluation of treatment standard. European

Orthodontic society has recommended IOTN and ICON for use in

comparative epidemiological and clinical studies between European countries. As

malocciusions are anomalies and not pathological conditions, they do not

demand immediate attention like diseases, and treatment is often provided for the

convenience of the patient (Ackerman, 1991). The elective nature of many

orthodontic treatments is also proved by Shaw et al (1989). In this longitudinal

study he found that only severe malocclusion traits, such as, increased overjet

greater than 6 mm, traumatic deep overbite and impacted teeth, have influence on

dental health. On the other hand McLain and Proffit (1985) have stated that

occlusal "..... problems cannot be defined solely in physical terms". They say

that the psychosocial consequences due to unacceptable dental esthetics may be

as serious, or even more serious, than the biologic problems.

In orthodontics the agreed treatment plan emerges as a result of both a

professional and a patient centered evaluation.

There are several studies which demonstrate that approximately 70% of referrals

to the orthodontists were initiated by the dentist (Thilander, 1984; Gossney,

1986; Shaw. 1979).

In literature we can find studies investigating differences of perceived

orthodontic treatment between patients and specialists. The results are divergent

Myrberg and Thilander (1973) in their study assessed orthodontic treatment need

in 5459 schoolchildren and concluded that 74% were in need of treatment.

However 21,2% of those who needed treatment refused it, because of treatment

duration and long travel distance to a specialist clinic. Also Espeland et al (1992)

in their study with Norvegian Treatment index found that 60% of individuals

who needed orthodontic treatment did not want it.

However Holmes (1994) assessed orthodontic treatment need and desire for

treatment in 955 British schoolchildren. They found that patients level of concern

may be reasonably correlated to a professional assessment of treatment.

In their discussion Touminen et al (1994) have pointed out a secular trend in the

results of need and demand studies, suggesting that public perception of

treatment need may be moving towards that of the orthodontic professional.

Many different factors must be considered before orthodontic treatment is

initiated. At orthodontic consultations specialists assess treatment need, diagnosis

and treatment possibilities of the patient. Age, treatment difficulty, long term

prognosis treatment benefit and demand and other factors are also considered.

This leads to a preliminary patient selection. Concurrent with growing increase in

the costs of orthodontic care and reduced resources, the demand for this process

of priority to be built on a firm foundation is increasing.

In recent years, the scientific basis for health care has gained greater attention

among health professionals, patients, national and regional health authorities.

They seek improved justification for health care practices and policies based as

much as possible upon careful appraisals of available evidence (Goodman,

1993).

A consumer's satisfaction with the quality of a service can be thought of as the

extent of discrepancy between his or her expectations and subsequent lasting

perceptions after the service is rendered (van der Heijden, 1993). Yet satisfaction

appears to be a multidimensional construction that can vary significantly among

people and over time (Aharoney, 1993; Kane, 1997). Donabedian suggested that

methodologies used to evaluate the quality of health care should be based on the

following aspects: structure (evaluation of facilities, equipment, personnel,

organization and treatment cost), process (patient - provider interaction), and

outcome (measures of health status and patient outcome).

Presently, no single instrument exists that can effectively measure the quality of

oral health care delivery (Antezak - Bouckoms, 1995). Although the patient's

perceptions of their relationship with the orthodontist (the process) and of the

treatment results (the outcomes) are important, final feelings of satisfaction are

most closely associated with'the initial expectations of treatment. Meeting patient

expectations has been found to be related to increased consumer satisfaction

(Hsieh et al, 1991) orthodontic treatment effectiveness.

Although the dements of satisfaction and expectation in orthodontics have been

previously defined (Davis, 1981) their interrelationship is not well understood.

Orthodontic consumer, principally parents of young children, has been found in

several studies to seek care for their children will benefit in terms of their

appearance (Shaw, 1975). These studies also showed that parents expect

orthodontic treatment to provide social benefits.

Professional assessment of effective orthodontic treatment is more based on the

evaluation of the treatment result, if the occlusion is close to ideal (Andrew

6 keys). There are numerous studies which evaluate and compare treatment

results using occlusal indices (Shaw, 1991; O'Brien, 1993; Richmond and

Andrews, 1993; Turbill et al, 1996). Studies by Bergstrom and Hailing (1996 ab)

about orthodontic treatment outcomes in three different Swedish countries

proved the role of organization and specialist resources in the effectiveness of

orthodontic care.

The wide variation in organization and resources internationally (Moss, 1993) as

well as nationally (Bergstrom and Hailing, 1996) obviates the necessity of

relating results of treatment to the structure of the service in order for

comparisons to be valid.

Actuality of the work

In epidemiological surveys the professionally determined need varies widely and

depends on the age, gender, type of population studies and the cut off levels for

severity of malocclusion (Holmes. 1992; Brook and Shaw, 1989; Proffit, 1998;

Cooper, 2000).

In many countries worldwide occlusal indices have been successfully used and

given useful information about the severity of malocclusion and effectiveness of

treatment delivered.

Our aim is to assess in detail- orthodontic treatment need in Latvian population

using occlusal index (ICON).

The question about effectiveness of orthodontic treatment carried out is

important. There is no such full information obtained in Latvia about orthodontic

treatment need, demand and effectiveness until now. This information is

important to plan resources and to satisfy the need and demand for orthodontic

treatment.

The aim of the study

To assess the need and effectiveness of orthodontic treatment in Latvian health

care system using scientifically approved methods.

The tasks of the study

1) To assess the severity of malocclusion and orthodontic treatment need in

population of 12-13 year old schoolchildren

2) To evaluate the subjective attitude to their own malocclusion and their desire

for treatment

3) To assess the effectiveness of orthodontic treatment according to the severity

of malocclusion, patient self-perception, treatment method and duration.

Methods

ICON

The index of Complexity, Outcome and Need (ICON) has been developed

(Daniels and Richmond, 2000) based on the average opinion of 97 practicing

specialists orthodontists from nine countries (Richmond and Daniels, 1998). It is

a single assessment method to quantify orthodontic treatment complexity

outcome and need. The reliability and validity of the index is evaluated in several

studies. Firestone (2002) for assessing the reliability of the method used the

opinion of 15 specialists. The ICON result and experts opinion were good in 155

cases from 170.

Table \. ICON scoring method

SCORECOMPONENT 0 1 J 4 5 WeightI. Aesthetic assessment

Score 1-10 7

2. Upper arch crowding

<2mm 2.1 to 5 mm

5.1 to 9 mm

9.1 to 13mm

13.1 to 17 mm

>17mrn 5

Upper arch spacing

<2 mm 2.1 to 5 mm

5.1 to 9 mm

>9mm Impacted tooth

5

3. Corssbite Not present present 5

4. Incisor open bite

Complete bite <1 mm 1.1 to 2 mm

2.1 to 4 mm

4

Incisor overbite <l/3 lower incisor covered

1/3 to 2/3 covered

2/3 up to fully

covered

Fully covered

4

5. Buccal segment antero-posterior

Cusp toembrasure

noly; Class I; tt or III

Any cusp relation up to but not including

cusp to cusp

Cusp to cusp

3

Aesthetical component

The ICON consists of five components: The Aesthetic Component (AC), upper

and lower crowding/spacing, assessment, presence of a crossbite, degree of

incisor open bite /overbite, and fit of the teeth in the bucal segment in terms of

the anterior posterior relationship. Each component can be measured on study

casts as well as on patients. The practical application of the index is simple and

takes approximately one minute for each case.

The questionnaires

Information about children's own perception of their dental appearance and

demand for orthodontic treatment was collected by means of a self administrated

questionnaire. The answers were assessed using a Liker type scale- The number

of items chosen on the scale was five. All participating schoolchildren completed

the questionnaire in the school dentist's office.

In order to compare our results with other studies, our questionnaire was based

on the previously developed analogues (Stenvik et al, 1996.; Pietila, 1996). To

evaluate the effectiveness of treatment results from the patient' point of view we

developed a questionnaire. With the help of this self-administered

questionnaire we gathered information about the patient's own perception and

attitude to the existing malocclusion before and after orthodontic treatment. This

questionnaire was developed taking into account the criteria suggested by Carey

(1993). The patient completed the questionnaire in the waiting room at the end of

the orthodontic treatment. The patient questionnaire was on an A4 form. The

patient perception and attitude to the existing malocclusion was assessed using a

Liker type scale.

The criteria for selecting questions in the cost part of the questionnaire were

based on the relevant economic factors relating to the health care provision, as

explained in the literature review. More specifically, the questionnaire addressed

the distance traveled, the total time involved in the visit, the alternative use this

time and the occupation of the main breadwinner of the household.

Material and protocol

To realize the aim of our study we set three tasks. To fulfill these tasks we

developed several study groups.

Orthodontic treatment need and subjective demand study group

Five hundred and four schoolchildren aged 12-13 years from five rural schools

and four urban schools were examined using the ICON index.

These schools and schoolchildren were selected according to the World Health

Organization ICS II criteria (1993). One orthodontist screened all children using

the ICON in a dental setting in the schools. According to the second task the

children were also invited to complete a questionnaire about treatment need and

their appearance (Appendix 1).

Table 2. Distribution of schoolchildren and schools.

Settings (number of schools)

Number ofschoolchildren

%

Riga (2)

Ventspils(l)

Daugavpils (1)

149

48 48

29,6

9,5

9,5

Saldus (1)

Madona (1)

Limbazi (1)

Jelgava(!)

56

50

50

54

11,1

9,9

9,9

10,7Valmiera(l) 49 9,7

Total: 504

Assessment of effectiveness of orthodontic treatment

Study groups

To assess the effectiveness of treatment carried out in the Orthodontic clinic of

Institute of Stomatology 73 dental casts pre and post treatment were examined

using the ICON index. The patients were aiso invited to complete a questionnaire

about self-perception and attitude to the existing malocclusion (Appendix 2).

According to the severity of malocclusion before treatment and to the treatment

method all patients were divided into two groups. In the first group we included

40 patients (14 boys and 26 girls) who had mild and moderate malocciusions and

were treated with fixed systems in both arches. The mean age of patients was

16,5 years ± 3,5 years. In the second group we included patients with severe and

very severe malocclusions. They were treated by means of orthodontics and

orthognatic surgery. The mean age of patients in this group was 20,5 years

±1,3 years.

Statistical analyses

The proportions of children in different schools needing treatment, as defined by

having an ICON score of at least 44, were compared using Pearson x2 test. ICON

scores between the schools and settings were compared using one way analysis

Descriptive statistics, including means, standard deviation, and ranges were

calculated for the questionnaire results, treatment and ICON scores.

The frequencies of different factors were analyzed using Pearson x test. A

probability at the 5% level or less was considered statistically significant. The

differences in mean treatment duration according to mean self-perception were

evaluated by the analyses of variance.

The statistical significance of differences betweens groups and before and after

treatment was evaluated by standard t-test.

Results

The severity of malocclusion and orthodontic treatment in population of 12-13

aged schoolchildren

The prevalence of malocclusion for eight schools is shown in Figure 1. Figure 1.

Percentage need for orthodontic treatment in Latvia using the ICON.

The need for treatment, according to an ICON score of at least 44, ranged from

27,5 to 58,3 percent. The differences between these percentages were statistically

significant (p< 0,01). There were no significant differences between urban and

rural areas, with 34 percent of subjects in rural areas and 37 percent in cities

needing treatment. Thirty two percent of boys needed treatment, compared with

37 percent of girls, but this difference was not significant.

The box plot (Fig. 2) shows the distribution of scores in various schools.

Analysis of variance confirmed that there were no differences between

urban/rural areas and for between boys and girls. However, it did show that there

were significant differences between schools, the multiple comparison tests

indicated that the difference between Riga, with a mean of 27,5, and Daugavpils,

with a mean of 48,5, was significant (< 0,01).

Figure 2. Distribution of ICON scores (box plots) for the nine urban (U) and

rural ® settings in Latvia. (The box shows the 25'h to 75lh percentile with the black line

mean score. The wisker represents the smallest and largest outlying values. The circles and

numbers represent the outliers.)

Regarding treatment complexity (Table 3), the degree of difficulty did not vary

significantly between schools (very difficult ranging 1,3-10,4%). Only 10 percent

were considered "Difficult or very difficult".

Table 3. Distribution of orthodontic treatment complexity between the urban (U)

and rural(R) settings using ICON.

Settings Easy Mild Moderate Difficult Very difficult Total (n)

Daugavpils (U) 22,9 35,4 18,8 12,5 10,4 48

Riga (x2) (U) 36,9 44,3 14,8 2,7 1,3 149

Ventspils (TJ) 29,2 39,6 14,6 14,6 2,1 48

Jelgava (R) 33,3 48,1 9,3 5,6 3,7 54

Limbazi (R) 48,0 40,0 12,0 4,0 6,0 50

Madona (R) 40,0 34,0 16,0 4,0 6,0 50

Saldus (R) 37,5 39,3 14,3 7,1 1,9 56

Valmiera (R) 30,6 46,9 12,2 6,1 4.1 49

Total (%) 34,3 41,7 14,1 6,2 3,8

Schoolchildren self perceived orthodontic treatment need With regard to the

questionnaire, the responses were compared with those individuals needing and

those not needing treatment according to the ICON. Statistically significant

differences occurred with respect to questions 1., 2. and 7. These were also the

only questions in which the scores were correlated with the ICON score. For

question 1 those dissatisfied with the arrangement of their teeth were more likely

to require treatment according to the ICON; similarly for question 2 those who

wanted their teeth to be straightened were more likely to have a clinical need

according to the ICON. For question 7, 49 percent of those who thought they

needed treatment did so; 26 percent of those who were unsure needed treatment,

and 26 percent of those who said they did not need treatment were judged to

need it. There were differences between boys and girls for questions 1., 2 and

7.

There is a consistent: girls were more likely than boys to be dissatisfied and

judge that they needed treatment. The dissatisfaction with the dental appearance

was 35 percent of all schoolchildren and 67 percent wanted their teeth

straightened. There were no statistically significant differences for either

question 1 or 2 between urban and rural settings.

Effectiveness of the orthodontic treatment

A total of 73 individuals study models pre and post treatment were scored

applying ICON. All patients were invited to fill in the questionnaire. There was a

100 percents response rate for the study.

Patients were divided into two groups according to the severity of malocclusion

and treatment method.

ICON score pre and post treatment

Table 4 shows the mean ICON scores pre and post treatment in both groups.

Pretreatment score was significantly higher in the severe malocclusion group (p <

0,01). The mean values after treatment were not statistically different between

two groups. According to the improvement grade in category "greatly and

substantially improved" there were 85 percent of cases from moderate

malocclusion group and 87,9 percent of cases from severe malocclusion group.

Table 4. Mean score of selfperceived dental appearance (standard deviation) and mean ICON score in group 1 and 2.

Group 1 Group 2 PSelfperceived dental appearancebefore treatment

1,40(0,84) 1,36 (0,69) NS*

Selfperceived dental appearance after treatment

4,3 (0,79) 3,97 (0,95) 0,1

Selfperceived communicating problems before treatment

1,30(0,65) 2,58 (1,39) 0,001

Selfperceived communicatingproblems after treatment

1,15 (0,48) 1,21 (0,48) NS

Problems with biting and chewing before treatment

1,50 (0,87) 2,18(1,18) 0,01

Problems with biting and chewing after treatment

1,30(0,61) 1,15 (0,36) NS

ICON score before treatment 63,45(18,91) 84,58(10,82) 0,001ICON score after treatment 17,18(5,98) 18,52(6,86) NS*No statistical difference between groups

The mean treatment duration was statistically different between groups (p <

0,01). Patients with moderate malocclusion were treated on an average 18,5

months (± 6,7 month) but patients with severe or very severe malocclusion were

treated on an average 27,9 month (± 6,1 months).

Tables 5 and 6 show a relationship between the improvement of malocclusion

measured by ICON and the mean treatment duration.

Table 5. Relation ship between improvment and treatment duration in group 1.

Improvement grade

Greatly improved

Substantialy improved

Moderately improved

Minimaly improved

Not improved or

worseMean treatement duration (months)

20,6 16,7 16,2 12,0 30,0

SD 8,1 5,0 3,3 0 0

* SD - standard deviation Table 6. Relation ship between improvment and

treatment duration in group 2.Improvement grade

Greatly improved

Substantialyimproved

Moderatelyimproved

Minimaly improved

Notimproved or

worseMean treatement duration (months)

27,3 27,1 32,8 - -

SD 6,2 5,2 6,7 - -

* SD - standard deviation

There were no statistically significant differences between the improvement

grade and treatment duration within scope of each group.

Patients' self perception of malocclusion and treatment result

Before orthodontic treatment 92 percent of all patients in both groups were

dissatisfied and partly satiesfied with their dental appearance. In the moderate

malocclusion group (group 1) 90 percent of patients did not tike the aesthetics of

their teeth but in severe malocclusion group (group 2) there were 95 percent of

such patients.

Figures 3 and 4 show the self-perception of dental appearance in both groups

according to the gender of a patient.

Figure 3. Self-perceived dental appearance before orthodontic

treatment in group 1.

Figure 4. Self-perceived dental appearance before orthodontic

treatment in group 2.

After treatment 94 percent of respondents reported that they were "satisfied" or

"very satisfied " with their dental appearance. AH patients in the moderate

malocclusion group (group 1) were "satisfied" or "very satisfied" with their

dental appearance after orthodontic treatment. In the severe and very severe

malocclusion group there was a slight difference, but it was not statistically

significant. After orthodontic treatment 6 percent or 2 patients in this group

reported that they are not satisfied with their dental appearance. Figures 5 and 6

show the patient self-perception of their dental appearance in both groups after

treatment according to the gender.

Figure 5. Self-perceived dental appearance after orthodontic treatment in group 1.

Figure 6. Self-perceived dental appearance after orthodontic treatment in group 2.

With respect to self-perception of treatment result the majority of patients, 74

percent of all respondents, rated their treatment as "very successful" and 24,5

percent as "successful". There was one patient in the severe malocclusion group

(group 2) who was not satisfied with the treatment result. There was also a

statistically significant difference in the treatment result evaluation between

groups according to the gender. In the severe and very severe malocclusion group

female patient self perception of treatment result was lower than male patient -

mean score 3,7 points for females and 4 points for males.

Tables 7 and 8 show a relationship between patient's self perceived treatment

result and treatment duration in both groups.

Table 7. Self-perception of treatment results due to treatment duration group I.

Self-percpetion of treatment result

Satisfied More than satisfied

Very satisfied

Mean treatment duration 23,9 19,0 15,9

SD 8,7 6,2 4,7

Table 8. Self-perception of treatment results due to treatment duration group 2.

Self percpetion of treatment result

Dissatisfied Partly satisfied

Satisfied More than satisfied

Very satisfied

Mean treatment duration

38,0 33,0 36,7 28,9 26,6

SD 0 0 6,1 5,2 7,0

We revealed a tendency in the moderate malocclusion group that patient whose

treatment time was shorter were more satisfied with the treatment result.

Difficulty with mastication

Overall 58,9% of all respondents reported no problems with masticator function

before orthodontic treatment. There was a statistically significant difference

between the two groups (p ± 0,01). In the moderate malocclusion group 17,5%

reported "some difficulty" and 'great difficulty", but in the severe and very

severe malocclusion group 24,2% reported "some difficulty" and 18,2% "great

difficulty" with chewing before treatment.

After treatment 80,8% of all respondents reported no problems with biting and

chewing. There was also no statistical difference between the two groups.

Comparing the answers before and after treatment we observed significant

improvement in self-evaluation of masticator function in the severe and very

severe malocclusion group.

Methods

The ICON is a relatively new index and is just beginning to be used more widely.

It has been shown to be a reliable and valid index (Koocher wet al, 2001;

Firestone et al, 2002) for assessing orthodontic treatment need and outcome. The

accuracy if the indexes reflect professional opinion for a diverse sample of cases

was estimated at 84 percent for decisions of treatment need and 68 percent for

treatment outcomes. The method is heavily weighted by aesthetics (Daniels and

Richmond, 2000).

The ICON can be used to assess the treatment need, severity of maloccfusion as

well as treatment outcome. This was the prerequisite to use this method in our

study.

Questionnaire is a widely used method for evaluation of patients' attitude to their

malocclusion and orthodontic treatment. This method allows to standartize the

criteria and has been used in numerous other studies for subjective assessment of

orthodontic treatment (Espeland, Cons, Helm).

The advantage of the Liker scale, used in answers, is that it is based on a single,

linear underlying continuum. This linear interval scale permits us to treat scores

integers which may be added, subtracted and multiplied. This scale also allows

the subjects to place themselves on an attitude continuum for each statement. The

reliability of a Liker scale tends to be good. This may be because of the greater

range of answers permitted to respondents. Respondents tend to prefer to express

a degree of satisfaction rather than respond to "satisfied" or "not satisfied"

questions.

The severity of malocclusion and orthodontic treatment need in population of 12-

13 year old schoolchildren. The mean level of treatment need of 35,3 percent

across all setting is similar to other studies in England and Wales (Brook and

Shaw, 1989; Burden and Holmes, 1984; Office for population Censues and

Surveys, 1994). But this figure masks a considerable variation between schools.

For example, a greater need was found in Daugavpils (58,3%) than in Riga

(27,5%). This difference is not fully explained. It is possible that those variations

are related to factors not investigated in our study and need further investigation

to evaluate those reasons. There are no statistically significant difference in

treatment need between rural and urban settings and this is similar to other

studies (Tullock, 1984; Bergstrom and Hailing, 1996).

Regarding the severity of malocclusion, 10 percent or schoolchildren have severe

or very severe malocclusion. In literature also we can find that the severity in

population varies from 5% to 14% depending on the method used for assessing

malocclusion and on the patients' age (Ratchiller and Ingervall, 1984; Shaw et

al, 1989). Our data reveal that ICON is more sensitive in showing the degree of

severity of malocclusion and the treatment need in general as well as it better

reacts on regional variations when comparing with results in PVO ICS II project

(1993).

We can't underestimate the individuals concern for their own dental appearance

as it represents a decisive factor in the demand for treatment and assessment of

treatment goals (Stenvik; Shue Te Yen M).

Interestingly, in our study the need for orthodontic treatment determined by the

ICON score is related to the individual's subjective assessments of satisfaction of

appearance and the perception of need to straightness their teeth. We found no

statistical difference between answers about subjective satisfaction with dental

appearance and self-perceived need for treatment. There findings is similar to

other studies (Shaw; Helm).

The need of boys and girls were not found to be different but their self-perceived

needs were different, with girls feeling more in need of treatment than boys.

Previous studies also have shown that females are more dissatisfied with the

appearance of their dentition than males (Shaw; Sheats) as well as females

perceive a need for braces more often than males (Wheeler). The results show

that there are no considerable regional variations in subjective assessment of

dental appearance and selfperceived need.

In previous study carried by World Health Organization ICS II in 1993

subjective need for orthodontic treatment expressed 19 percent schoolchildren

aged 12-13 years. On the contrary in our study 65 percent of schoolchildren

wanted their teeth straightened. These differences in self assessment can have

happened because of increasing role of facial appearance in the society and

availability new methods of treatment. It is state that improving socials economic

level lead to increasing self perceived need for improving individual's esthetic

appearance, including teeth (Proffit WR, 1998).

Evaluation of Efficiency of Orthodontic Treatment

In evaluating the efficiency of orthodontic treatment, clinically the most often

used method is comparison of occlusion models prior and after treatment, thus

determining the introduced changes during the treatment process. However, this

method reviews only part of the whole orthodontic treatment process.

The study groups are sufficiently presentable within the scope of one clinic. Our

study groups in some respect do not represent the whole population, but it is

presentable from the point of view of the occlusion anomalies treated in the

Stomatology Institute and Latvian regional representation. This could be

regarded as classical population, to which orthodontic treatment is provided on a

regular basis in the Stomatology Institute. In the first group the largest group of

patients is schoolchildren, which is also evidenced by the average age of 16,4.

As it was expected the mean age of patients among the groups was varied, since

to the patients included in the second group with heavy and very heavy occlusion

anomalies orthodontic and orthognatic therapy is performed after the end of

growing. The mean age of this group - 20,5 years - evidences that young people

are readier to accept more cardinal treatment methods. In some respects it could

be related to the fact that they link the rise of their socio-psychological status in

the future life with correction of occlusion anomalies. Although, in the first

group the mean age was expected to be higher taking into account the increasing

desire to receive orthodontic treatment of grown-up patients, the results of this

research do not prove that. It could be partly explained by expansion of the

private sector. Perk (1997) concludes that a large part of the grown-up patients

are more treated in private practices than are referred to university clinics. The

other factor could be a speculative opinion of the society, that orthodontic

regulation is possible and could be performed in adolescence and that appliance

is aesthetically noticeable and could cause discomfort in relations with other

grown-ups.

In respect to the gender of patients women were proportionally more represented

in both groups. It could mean that occlusion anomalies are a greater concern to

girls than boys and they want to correct them. Thus, the tendency complies with

other published research (Shaw, 1981; Sheats, 1998; Wheeler, 1994). It is

interesting that an even greater difference between gender is found in the second

group, where anomalies are heavy or very heavy. However, either Barber et al

(1992) or Beily et al (2001) in their research on division of orthodontic patients

and their wishes hold a similar opinion. Hence, we may conclude that women

more frequently wish to receive treatment and more often agree to the offered

therapeutic possibilities.

The mean initial ICON indicator is 63 and respectively 84 points, which show

that most patients have severe or very severe anomalies. These indicators comply

with the data received in other research on orthodontic treatment in university

clinics (Espeland and Stenvik, 1991; Birkeland et al, 1999, Firesotne, 1999). In

our research 93,1% of the patients fell into the category of necessity for

treatment and only 6,8% or in respect to 5 patients the value of ICON was less

than 43. All these patients were in the first group, where the pre-treatment

severity level was moderate. It could be explained by the fact that the decision on

orthodontic treatment is a joint combination of wishes and needs of the patients

and/or their parents and specialists (Shaw et al, 1981).

However, the treatment result according to ICON in both groups is not

statistically different. It means that notwithstanding the severity of the occlusion

anomalies and therapy method, the obtained results have a high standard, and

from the point of view of treatment result it can be considered that the therapy is

effective. It relates to the data obtained in Richmond and Andrew (1993) research

on evaluation of the results of orthodontic treatment performed by specialists in

Norway.

Similarly AL Yami investigated the result of orthodontic treatment in Nimmingen

University clinic in the Netherlands, and 91% of the evaluated results was

included in the section of "considerable improvement" or "improvement". The

latest literature show increasing number of data on wishes of patients,

treatment results and patient satisfaction interaction in respect to orthodontic

treatment, however, there is no unequivocal opinion or definite indicators {Vig,

1999; Bos et al, 2003). In our research the satisfaction of patients and wish for

orthodontic treatment was determined by their attitude towards the appearance of

their teeth before and after treatment, the evaluation of the orthodontic treatment

result, as well as evaluation of the occlusion function before and after therapy.

The research is retrospective, since the patients filled in the questionnaire after

completion of the treatment; such an approach can also be found in other

literature data, when past and present evaluation questions are combined in one

research to determine psychosocial aspects of occlusion anomalies. In subjective

evaluation of the self-perceived dental appearance prior to treatment there was no

statistically considerable difference among groups and gender, which means

that all patients mostly wish to improve their looks. Very often individuals, who

are not satisfied with their looks, mention the bad likeness of teeth as the

reason for that. Therefore, most people consider orthodontic treatment as

dentofacial improvement (Albino, 2000; Giddon, 1984; Lew, 1993). The obtained

results on self-evaluation of patients after treatment are not that homogenous as

the evaluation prior to the therapy and as was expected.

Looking deeper into the division of gender, we concluded that particularly

women were not satisfied with the result reached by therapy and the appearance

og their teeth (though, these results are not statistically credible). It could be

explained by the fact that women are more concerned with improvement of their

looks. Similarly Philips (1997) in his research on factors, which make individuals

visit an orthodontic consultation, concludes that men link improvement of their

looks and functions with social welfare changes, while women are more

interested in looks as such. The fact that most patients in both groups were

satisfied with the appearance of their teeth and the result of therapy conforms

with other carried out research (Kiyak, 1986; Busby, 2002). The observed

dissatisfaction with the appearance of teeth after therapy could be explained by

an understanding that the larger the dissatisfaction with the look of the face, the

larger and the better treatment the patient wishes to receive (Shaw, 1981;

Cunnigham, 2000). The obtained data also comply with the point of view that

there are differences among the sexes in perception of treatment results

(Goosney, 1986). It is possible that in this case the wishes of patients were not

fully found out or the obtained result did not comply with the expectations. Such

an opinion is expressed by Kiyak (1986; 1998) and Philips (1997) in their

research on subjective self-evaluation of patients.

Hence, we must agree with the conclusions of Jacobsen (1984) that

notwithstanding the numbers of the patients satisfied with the result of the

treatment, it is important to pay attention to those patients, who have expressed

dissatisfaction with the achieved result. He decides that not always an ideal result

will be reached, but in cases when the aesthetic changes will not be that explicit

or will be limited, it is vital to inform the patient about that and not let the patient

think otherwise.

Considering the above mentioned indicators: ICON result before and after

treatment, self-evaluation of the likeness of the teeth of patients, division among

pathology groups of self-evaluation of communication and functional problems

prior and after therapy, the obtained results show that the planned orthodontic

therapy result is reached, which is evidenced by the statistical difference in the

beginning of treatment and non-presence of statistical difference at the end of the

treatment either in the objective ICON or subjective self-evaluation.

The results of our research conform to the data of Bergstrom et al (1998) on the

average length of treatment in a specialist clinic. Jarvinen (2002) analyzing

efficiency of orthodontic treatment in Finland notes that the average length of

treatment is 2,8 years. Although there are differences among groups in respect to

the length of treatment, the average indicators comply with the results obtained

in other research (Richmond and Andrews, 1993; Birkerland, 1997; Fox and

Chadwik, 1994). Interesting that when comparing the objectively obtained results

on the level of occlusion improvements, the results show that the patients in the

first group, who have had a longer period of treatment, have greater

improvement. This relationship could be explained by that the initial occlusion

anomaly of these patients was larger {Richmond, 1993). No relationship was

observed within the second group, which could indicate that the initial anomaly

of all patients was similarly severe.

In order to better evaluate the satisfaction of patients with orthodontic treatment

we determined the judgment about their self-evaluation and results of treatment

depending on the length of treatment. The results of our research showed that in

the first group the self-evaluation of patients is higher, if the length of treatment

has been shorter. Seemingly in replying to the question about self-evaluation of

the appearance of teeth after treatment in the questionnaire the patients

psychologically relate it to the length of wearing the orthodontic appliance.

While in the second group where the occlusion anomalies were very heavy, no

such relationship was established. It shows that the patients understand that the

anomaly is very heavy and requires lengthy treatment and therefore the time

factor has no relevance.

Summary

Distribution of occlusion anomalies and determination of necessity of

orthodontic treatment are important factors in planning of orthodontic treatment.

The information on attitude of patients towards their occlusion anomalies has

increasing importance. We in our research determined the necessity of

orthodontic treatment in the population of 12-13 year old schoolchildren and

found out the self-evaluation of school children, because it is difficult to create

and organize serious care system without good evaluation of the necessity of

orthodontic treatment and wishes or demand. The indicator of necessity for

orthodontic treatment obtained in our research complies to the results of

epidemiological research performed in other European countries. However, we

established considerable regional differences between the schoolchildren in Riga

and Daugavpils. It is difficult to explain these differences, because seemingly

there are some additional factors for investigation of which further detailed

research is required. For determining the necessity for orthodontic treatment we

used the occlusion index ICON, because this method is widely used and is

recognized as an objective means to determine distribution of occlusion

anomalies and the severity level in epidemiological research. ICON is a

relatively new index, but the results of our research and literature evidence that

with the help of it, it is possible to determine objectively the necessity for

orthodontic treatment and the severity level of occlusion anomalies in the

population, and it is sufficiently sensitive to show differences in necessity for

treatment within the scope of population.

Since orthodontic treatment has a certain factor of choice in comparison with

other fields of medical care, determination of the attitude of the patient towards

the appearance of the teeth and wish for treatment is vital. In our research

individual self-evaluation of appearance of the teeth and wish for orthodontic

treatment statistically significant correlates with the clinically determined

necessity discovered by ICON.

It is essential to evaluate the changes of individual wishes and self-evaluation

within a longer period of time. Within ten years the subjective self-evaluation of

individuals and demand for orthodontic treatment in Latvia have considerably

altered. The desire to correct teeth has grown several times. Seemingly the

importance of looks has grown in the socio-psychological field and new more

effective treatment methods are available, since in any relationship upon

improvement of general socio-economic indicators, the wish to improve the

looks grows as well.

Clinical audit or evaluation of orthodontic treatment efficiency is a systematic

method to assess whether the determined treatment results are reached and to

introduce further enhancement. In the Stomatology Institute Orthodontic Clinic

orthodontic treatment is provided to patients with mild and severe occlusion

anomalies. The patients, who visit the orthodontic specialists, are from the whole

country.

Notwithstanding the objective level of occlusion anomalies, they look for high

quality assistance. As a result of treatment the objective evaluation, applying

ICON, depending on the severity of occlusion anomalies evidence that the

treatment provided in the clinic is of good quality and the set treatment aims are

reached. This is shown also by the first questionnaire of patients, which is a

subjective criterion for determining efficiency of the treatment. The objective

ICON indicator complies with the subjective opinion on the necessity for

orthodontic treatment and the result of the treatment, and it illustrates that

orthodontic treatment is effective notwithstanding the severity level of occlusion

anomalies. Also for the first time one of the factors for determining the quality of

life of patients - satisfaction with therapy, including cosmetic effect, mutual

communication, presence of functional disturbances - has been evaluated. Since

health of a mouth is part of general health and is related to the quality of life of

the patient, contemporary understanding of the level of influence of orthodontic

treatment on the quality of life is vital. For the performed orthodontic treatment

to be efficient it is important to objectively inform the patient on the possibilities

of orthodontic treatment as well as to find out the wishes of the patient, since

creation of such an occlusion, which would satisfy the patient, functions best and

is stable in a longer period of time, is the basis of qualitative orthodontic

treatment.

Conclusions

1. The severity of malocclusion (severe malocclusion l,3%-10,4%) and the

orthodontic treatment need (35,3%) among 12-13 year old schoolchildren in

the population of Latvia is similar to the data of other developed countries.

2. The subjective evaluation of the school children of the appearance of teeth

and wish for orthodontic treatment is closely and statistically significant

related with the objectively determined necessity for orthodontic treatment.

3. The objective clinical evaluation of treatment effective assessed with ICON is

of high standard apart from the severity of malocclussion.

4. The patients subjective self evaluation depends on the gender, severity of

malocclusion and treatment duration.

5. Assessment of effectiveness of treatment is more related to the patients

subjective self evaluation. It does not depend on the severity of malocclusion,

treatment method and duration.

Publications:

1. A. Liepa, I. Urtane, D. Cakame / Epidemiology of Dentofacial Anomalies inLatvia/ Stomatologija, 2000/3, 14.-16.., ISSN 1392-8589.

2. A. Liepa, I. Urtane, D. Osleja. "Occlusal indices and their practical use","Stomatologija", 2000/3, 26-28., ISSN 1392-8589.

3. A. Liepa, I. Urtane / Dentofacialo anomaliju subjektlvais un objektlvaisnovertejums / LMA/ RSU Zinatniskie raksti 2001/2 254.-256., ISBN 9984-550-53.

4. A. Liepa, I. Urtane / Use of ICON in treatment outcome assessment of severemalocclusions / Stomatologija, Lietuva, 2002/1, 33.-35., ISSN 1392-8589.

5. A. Liepa, I. Urtane, S. Richmond, F. Dunstan / Orthodontic treatment need inLatvia / European Journal of Orthodontics 25 (2003), 279 - 284.

1. A. Liepa, I. Urtane / Orthodontic Treatment Standard in Specialist and Non-specialist practices in Latvia / Stomatologija, Lietuva, 2003/2, 48-51, ISSN 1392-8589.

1. Appendix 1.

Name, Surname____________________________________

Age_____________________________________

1. Are you satisfied with the arrangement of you teeth?

Very satisfied o

Satisfied a

I do not care a

Dissatisfied

n

Very dissatisfied a

2. Do you want your teeth straigthened?

Yes, definitely n

Yes, probably n

No, probably no a

No, definitely not a

3. Do you consider well aligned teeth important for overall facial appearance?

Very important a

Rather important □

Not important a

Not important at all

□

4. How satisfied are you with your dental health?

Very satisfied n

Satisfied □

Dissatisfied D

I do not care o

T do not know

a

5. How often do you brush your teeth?

Several times a day □

Once a day a

At least once a week a

Less than oncew a week d

6. Have you ever worn an orthodontic appliance?

Yes D

No n

T do not know □

• If -yes" who suggested treatment

Myself a

My parents n

Dentist n

Friend a

I do not know a

7. Have you ever thought you are in need of treatment?

Yes a N o □

T do not know

a

* If Myes" please give the main reason for your concern

Appearance of teeth is unsatisfactory □

Function of the dentition is unsatisfactory a

Cleaning of teeth is difficult a

Some other reason

I do not know n

Appendix 2

QuetionnaireName Surname

Age Gender MF

1

2

1. Are you satissfied with your dental appearance now?dissatisfied satisfied very satisfied

1 2 3 4 5

2. Oo you have any difficulty of chewing and biting now?no difficulty very great difficulty

1 2 3 4 5

3. How good was your cooperation during treatment.very bad average

1 2 3 4excellent 5

4. Are you satisfied with the treatment result?very dissatisfied dissatisfied satisfied very satisfied

(< 30%) (31-60%) (61-80%) (> 81%)1 2 3 4

5. Were you satisfied with your dental appearance before treatment?dissatisfied satisfied very satisfied

1 2 3 4 5

6. Have you had any difficulty with biting or shewing?no difficulty very great difficulty

1 2 3 4 5

7. How do you get to the ctinic?by foot by car bay train by bus taxi

1 2 3 4 5

a. How long is the distance to the clinic?

> 1 km 1-5 km 6-10 km < 10 km1 2 3 4

9. How much time do you spend on your way?

> 5 min 6-15 min 16-30 min < 30 min1 2 3 4

10. Your occupation?

11. Do you need specially take time off to, visit a specialist?YfiS No

1 2

12. If yes, please state the reasonday off leasure to cut school other:........................................................from work activities

1 2 3 4

13. The occupation of your main breadwinner.

14. How much time including waitting do you spend in the clinic?> 15 min 15-30 min 30-45 min < 45 min

1 2 3 4

15. Had you any problems in communicating with other people before treatment?no problem average very great problem

1 2 3 4 5

16. Do you have any problems in communicaty with other people now?no average very great problem1 2 3 4 5