# Comment

## Orthodontics and quality

In 1962, a report from the World Health Organisation (WHO) International Expert Committee on Dental Health stated that, ‘an anomaly should be regarded as requiring treatment if the disfigurement or functional defect is, or is likely to be, an obstacle to the patient’s physical or emotional well-being’.¹ There was no mention of ‘quality’ and all that it entails. More recently, the WHO introduced the multidimensional construct of ‘quality of life’. It was defined as, ‘people’s perception of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards, and concerns’.

In orthodontics we have tended to concentrate on improving the quality of treatment with the result there has been scant research on the psychological and related health gains of orthodontic treatment. This might reflect the challenging nature of outcome research in orthodontics. The expected benefits of orthodontic treatment can take many years to be realised, and the whole process of treatment and appraising outcomes may confound our ability to identify a benefit. The quality of an orthodontist’s work and the processes used to treat an anomaly are important, but surely the main issue is the role that treatment plays in improving the patient’s quality of life?

In this era of evidence-based practice, there is a need to ensure that the advice given by orthodontists to patients and their parents is accurate and based on the best available clinical evidence. Historically, it has been claimed that orthodontic treatment confers benefits beyond the psychosocial gains achieved by the improvement in dental appearance. Oral health related benefits such as reduced susceptibility to dental caries, periodontal disease, temporomandibular disorders and traumatic dental injury have been claimed, but the actual oral health benefits of orthodontic intervention are quite limited.²

The quality of life of individuals with craniofacial anomalies (CFA) may be complicated by impaired oral function, poor facial and dental appearances, poor social integration and extensive treatments.

Although psychopathology is not commonly associated with CFA, psychological problems have been reported. The lack of scientific information on the quality of life in CFA can be attributed to the low prevalence of CFA and the use of different non-condition specific measurement instruments.³ Recently, an internationally validated condition-specific instrument, the Child Oral Health Impact Profile (COHIP),⁴ has been developed to measure the quality of life in CFA and, hopefully, it will improve the information available.

The quality of life data for children are less well-developed than the data available for adults. Measurement difficulties arise in children because of the lack of a suitable concept of quality of life, problems caused by developmental changes, and the appropriateness of using a surrogate to make decisions. Over the past few years several measures have been designed to evaluate the impact of oral and orofacial conditions on the quality of life of children, and it is likely that these measures will progress along with the use of qualitative approaches.

The quality of orthodontic treatment has profound implications for the practicing orthodontist, the patient, policy makers and third party payers. Developing process and outcome measures to evaluate the quality of orthodontic care have become a mandatory component in determining the efficiency and effectiveness of contemporary evidence-based clinical practice. A prerequisite of these quantitative measures is that they should be reliable and valid, and reflect the clinician’s and the patient’s preferences and perspectives. Orthodontists typically evaluate the outcome of treatment by measuring morphological components of malocclusion, the duration of treatment and cephalometric changes, but orthodontic patients, especially adults, are usually more concerned with quality of life issues and oral health implications. These may result in disagreements between the clinician/provider and the patient/consumer when evaluating the success of orthodontic treatment. Methods to appraise and analyse the quality of life are rapidly developing and methodologically sophisticated fields.⁵
Much of the orthodontic treatment that is under-
taken on a day-to-day basis is justified on the basis of
improving the patient's psychosocial well-being.
Studying the quality of life in orthodontic patients
has the potential to provide information about treat-
ment needs and outcomes, and to improve care in the
long-term. In addition, orthodontists are increasingly
expected to show accountability with respect to the
effectiveness of orthodontic treatment and efficient
use of resources. Clearly, an evaluation of treatment out-
come, which includes both clinician-based quantita-
tive measures and measures from the patient's per-
spective, has the potential to describe broader values
and contribute to the quality of orthodontic treatment.

The long-term outcome of orthodontic treatment
from the patient's perspective needs to be evaluated in
the context of the maintenance and stability of the
orthodontic result. Additionally, the maintenance of
the quality of the orthodontic treatment from the
patient's perspective will be influenced by changing
values and competing events in their life, including
their health and well-being. Assessment of patient
values and preferences from the perceived quality of
their treatment may be quantified with utility
analysis. This serves as an objective measure that an
individual places on a particular health state or out-
come. Although this may vary with age, and pre-
sumably with the initial severity of the malocclusion,
it implies the making of rational decisions under
uncertainty and relates to the level of probability of a
desired outcome being achieved. For some patients
the quality of life may be affected adversely by even a
minor tooth rotation, whereas other individuals with
more severe malocclusions may be satisfied with the
quality of life and not interested in any orthodontic
treatment. Although occlusal indices and cephalo-
metric analyses are useful for measuring the success of
orthodontic treatment from the clinician's perspec-
tive, they do not necessarily measure the characteris-
tics that are of significance to the patient, their level
of satisfaction and, hence, the quality of orthodontic
treatment.⁶

One might regard the extraordinarily high demand
for orthodontic treatment as evidence of the benefit
of orthodontic treatment.⁷⁻⁹ Certainly, prospective
patients and their parents seem confident of a bene-
ficial outcome when starting treatment.¹⁰,¹¹ In recent
decades, health professionals have come under
increasing pressure to demonstrate the worth of their

treatment with factual evidence of benefits. For
example, dentistry has been urged by the US Institute
of Medicine to 'improve our knowledge of what
works and what does not work' in the advancement
of oral health objectives. The report noted, 'a focus on
health outcomes is essential for dental professionals
and dental services in achieving desired health out-
comes for individuals and communities, and cannot
simply be assumed, but must be demonstrated to
patients, other purchasers of dental services and
policy workers'.¹²

Although there are good modules of quality manage-
ment for the industrial organisations, their applicabil-
ity and effectiveness in the orthodontic office is insuf-
ficiently documented. Clearly, it is hard to apply
these modules to small organisational structures, such
as many orthodontic practices. Standardised objective
performance measurements and quality indicators for
orthodontic practice are yet to be developed and
studied: these remain a challenge for orthodontic
treatment providers.

Homan H. Javaheri

Dental Research Center
Shaheed Beheshti University of Medical Sciences
Tehran 19839
Iran

Email: drjavaheri@sbmu.ac.ir

Fax: (+98) 21 22557406

Ashkan Javaheri

Stanford University School of Medicine
Room 182-B
3801 Miranda Ave

Palo Alto, CA 94304
United States of America

Email: ashkxii@stanford.edu

References

1. World Health Organisation. Standardisation of reporting of dental diseases and conditions. Report of an expert committee on dental health. Geneva:WHO;1962.

2. Burden DJ. Oral health-related benefits of orthodontic treatment. Semin Orthod 2007;13:76-80.

3. Broder HL. Using psychological assessment and therapeutic strategies to enhance well-being. Cleft Palate Craniofac J 2001;38:248-54.

4. Dunlow N, Phillips C, Broder HL. Concurrent validity of the COHIP. Community Dent Oral Epidemiol. 2007 Aug;35 Suppl 1:41-9.

5. Cunningham SJ, O'Brien C. Quality of life and Orthodontics. Semin Orthod 2007;13:96-103.

6. Vig WL, Firestone A, Wood W, Lenk M. Quality of Orthodontic Treatment. Semin Orthod 2007;13:81-7.
COMMENT

7. Richmond S. Orthodontic treatment need, complexity, outcome and cost-effectiveness. In: Jones ML, Oliver RG, eds. Walther and Houston's orthodontic notes. Oxford, UK: Wright; 2000.

8. Ter Heege G. EURO-QUAL: towards a quality system for European orthodontic professionals (Biomedical and Health Research Series). Amsterdam, Netherlands: ISO Press; 1997. ISBN 9051993307.

9. Birkeland K, Katle A, Lovgreen S, Boe OE, Wisth PJ. Factors influencing the decision about orthodontic treatment. A longitudinal study among 11 and 15-year-olds and

their parents. J Orofac Orthop 1999;60:292-307.

10. Shaw WC, Addy M, Ray C. Dental and social effects of malocclusion and effectiveness of orthodontic treatment. Community Dent Oral Epidemiol 1980;8:36-45.

11. Shaw WC, Gbe MJ, Jones BM. The expectations of orthodontic patients in South Wales and St Louis, Missouri. Br J Orthod 1979;6:203-5.

12. Institute of Medicine. Dental education at the crossroads: challenges and change. Washington DC: National Academy Press;1995.