# Trends in Finnish Public Orthodontic Care from the Professionals' Perspective

Authors: Ilpo Pietilä; Terttu Pietilä; Juha Varrela; Pertti Pirttiniemi; Pentti Alanen
Journal: International Journal of Dentistry
 (2009)

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## Abstract

The study maps out orthodontic care in Finnish municipal health centres in 2001, describes changes during the previous ten years reported by chief dental officers, and assesses the views of orthodontists on current public orthodontic services. The data were collected by questionnaires sent to all health centres and all orthodontists in Finland. Of all 0–18-year-olds, 11% were receiving orthodontic treatment with an appliance (range 2–43% among the health centres). The most frequently used appliances were headgear, quadhelix, and fixed appliances. Limited economic resources and the lack of orthodontic expertise were mentioned by the chief dental officers as factors decreasing the volume of services. The orthodontists mentioned the large regional variation and the lack of national guidelines as the most important aspects that should be improved on a national basis. To bring about improvement, they suggested increasing the number of specialist orthodontists and the delegation of orthodontic tasks to auxiliaries.


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## Body

## 1. Introduction

In Finnish health centres, orthodontic treatment is an important part of children’s and adolescents’
dental services, all of which are free of charge up to the age of 18 years. In the
early 1990s, every fourth dental visit of children and adolescents to the
health centres was connected with orthodontic treatment [1]. However, during
the economic depression later in the1990s, most health centres had to restrict
their expenditure. At the same time, the focus in public dental health care was
gradually changing, and today, dental care for adults of all ages is also included
in the services.  Despite this
development, it is generally accepted that children’s dental services should
not be endangered. Each municipal health centre can decide on the extent of
services they want to deliver. Consequently, the access to orthodontic
treatment varies considerably [2, 3].In countries with publicly funded
orthodontic services, dentists play a dominant role in the initiation of
orthodontic treatment [4, 5]. The access to orthodontic treatment is influenced
by two main factors; the rates of referrals to orthodontists for assessment and
the sufficiency of services. According to Shaw et al. [6], the referral rate is
influenced by the thoroughness of examination, the consistency of the
assessment of treatment need, and the perceived efficacy of treatment.
Different guidelines have been developed for the assessment of orthodontic
treatment need, but they do not seem to have much impact on the practices of
the general dental practitioners [7]. In Finland, the most frequently applied method
in the assessment of treatment need is a 10-grade scale modified from Grainger’s
TPI-index [8] by Heikinheimo [9] that is used in the majority of health centres.
On the scale, grade ten represents the most severe malocclusions or
craniofacial malformations, and grade one no malocclusion. The most frequently
applied cut-off level entitling to treatment is 7. However, in different health
centres the cut-off level varies between grades 2 and 8 according to the
resources of the health centre [1].The availability of services is
greatly influenced by the distribution of orthodontic manpower. In most western
countries, the majority of specialists live in the largest cities or in the
most densely populated areas. In sparsely populated areas, this may lead either
to restrictions in access to orthodontic treatment or to orthodontic treatment
given by general dentists [10]. In Finland, the availability of specialist
expertise varies in different areas of the country. In most health centres, the
role of specialist orthodontists is central in diagnostics and treatment
planning, but general dentists commonly provide treatment at least in all centres other than the
largest health centres [2].When public orthodontic care of
children and adolescents is evaluated, it is important to study both the
changes in orthodontic services as such and the perspective of the entire dental
health care. The aim of this study was to examine orthodontic care in Finnish
municipal health centres in 2001, and to assess the prevailing state and
development during the past ten years as viewed by the local chief dental
officers and the orthodontic specialists working in the health centres.


## 2. Methods

In April 2002, two different semistructured
questionnaires were sent out to survey the views on orthodontic care in
Finland. A questionnaire was sent to all local chief dental officers in 276
Finnish municipal health centres. The questionnaire was based on an earlier
questionnaire, which mapped out the orthodontic care in Finnish health centres
in 1992 [2], and it inquired about the number of personnel involved in
orthodontic care, their work division, the number of orthodontic patients and
visits, the use of removable and fixed orthodontic
appliances, changes in orthodontic care in the previous ten years, and the
chief dental officers’ own view on what further orthodontic research is needed.
A follow-up letter was sent to the chief dental
officers who did not respond by the appointed time.Another different questionnaire was sent to all 146 specialist
orthodontists under 65 years of age living in Finland in 2001, regardless of their
type of employment. The names and addresses of the orthodontists were obtained
from the files of the Finnish Dental Society. The answers received concerning
the optimal timing of orthodontic treatment, the main indications for starting
treatment in children at each developmental stage of occlusion, and the respondents’
choice of appliances have been analyzed in a previous study [11].The present study includes only the answers of those respondents who
worked in the health centres as salaried specialists or consultant
orthodontists, or who provided commissioned orthodontic services for health
centres, because they possessed real facts about activities in health centres
instead of just beliefs. The orthodontists were asked to evaluate, in open
questions, orthodontic services and optimal work division in municipal health
centres, to report recent changes in their treatment practices, to give
suggestions for improvement of orthodontic care, and to suggest orthodontic
issues needing further research.Responses were received from 177
chief dental officers, and after a follow-up letter, from a further 30 respondents.
The total response rate was 76%. The nonresponding chief dental officers worked
mainly in small health centres covering areas with fewer than 10 000 inhabitants. Six nonresponding chief dental officers worked in health centres covering
areas with 10 000–20 000, another
six with 20 000–50 000, and one with
over 50 000 inhabitants.In all, a response was received from 83
specialist orthodontists. Thirteen of them had no connection with health
centres and were excluded from the study; 70 respondents working in or cooperating
with health centres were included in the study. Twenty-two of the 63 nonrespondents
worked in the health centres as salaried orthodontists, and ten cooperated as
consultant orthodontists with the health centres. The response rate was 68%, when
only the respondents and nonrespondents working in or cooperating with the
health centres were included.


## 3. Results

### 3.1. Orthodontic Care in Municipal Health Centres in 2001

Orthodontic services were provided in
all the responding health centres. The volume of orthodontic services was
measured by the percentage of 0–18-year-olds
wearing orthodontic appliances in 2001, the mean percentage being 11.4 (SD 6.4,
range 2–43%). The mean
percentage of children wearing an appliance was the highest in small health
centres with fewer than 10 000 inhabitants. The mean percentage was slightly smaller
in larger centres, but the differences were not statistically significant. The
percentage of orthodontic visits of all dental visits of the 0–18-year-olds was,
on average, 30.7 (SD 10.6, range 2–66% among health
centres), and the size of the health centre was not associated with the ratio
of orthodontic visits (Table1).Table 1
The volume of orthodontic services in
the health centres of different size groups in 2001 measured by the number of 0–18-year-old children
wearing appliances and by the share of orthodontic visits of all visits in the
age group of 0–18-year-olds.
Number of inhabitantsPercentage of 0–18-year-olds wearing an orthodontic appliancePercentage of orthodontic visits of all visits of
0–18-year-oldsmean (SD)mean (SD)Below 10 00013.6 (7.1)30.4 (10.0)10 000–19 99912.8 (6.3)30.7 (14.1)20 000–29 99911.9 (6.0)31.3 (6.0)30 000–50 00010.6 (4.4)32.6 (6.2)Above 50 00010.3 (6.4)30.1 (8.7)A quadhelix was the most frequently
used appliance in primary dentition, followed by an eruption guidance
appliance. A headgear was the most frequently used appliance both in the age
group of 7 to 9 years, and in the age group of 10 to 13 years (Table2).Table 2
The appliances mentioned as the first, second, and
third most frequently used appliance in the age groups 7–9 and 10–13 years.
(a)
First, second, and third most frequently used orthodontic appliances at the age of 7–9 years(N=205)
ApplianceFirstNSecondNThirdNHeadgear915932Quadhelix646432Eruption guidance appliance343541Removable plate648Functional appliance31618(b)
First, second, and third most frequently used orthodontic appliances at the age of 10–13 years(N=204)
ApplianceFirstNSecondNThirdNHeadgear914327Fixed appliance716944Functional appliance165854Eruption guidance appliance131220Quadhelix1277The most frequent way to obtain
orthodontic expertise, used by 74% of health centres, was by making a contract
with a consultant orthodontist. Every fifth health centre had employed salaried
orthodontist manpower. Commissioned services were purchased in 34% of health
centres. The purchasing of commissioned services was most frequent in the small
health centres with fewer than 20 000 inhabitants. Five percent of health
centres did not have any specialist expertise at their disposal. The ways of
obtaining orthodontic expertise in the health centres of different sizes are
given in Table3. Specialist orthodontists’ working time represented 22% of the
total working time spent on orthodontic treatments in all the responding health
centres.Table 3
How orthodontic expertise
is obtained in the health centres of different sizes, measured as the number of
inhabitants in the area.*
Size of health centre as the number of inhabitants (Number of health centres)Own salaried specialistPurchased consultant servicesPurchased commissioned servicesBelow 10 000 (100)2914010 000–19 999
(50)6411520 000–29 999 (22)1111430 000–50 000
(18)1084Above 50 000 (16)1426All
(206)4315369*Some health centres obtain
expert services in several ways.In almost all the health centres (94%),
general dentists treated some of the orthodontic patients. The working
time they spent on orthodontic treatments represented 64% of the total working
time spent on orthodontic care in the health centres.  Delegation of orthodontic tasks to dental
auxiliaries was used in 61% of health centres, and their working time
represented 14% of the total working time spent on orthodontic care in the
health centres.Seventy-four percent of chief dental officers reported major
changes in the organization of orthodontic services during the previous five
years. In thirty-four health centres, major changes had taken place in the
volume of orthodontic services (Table4). Most of these changes concerned
orthodontic specialist services. The number of specialist orthodontists had
increased in twenty-seven and decreased in seven health centres.Table 4
Changes in the volume of orthodontic
services during the previous five years reported by local chief dental officers
(N = 34).
Changes reported (N)Explanations given by respondents (N)Volume of orthodontic treatment increased (27)Specialist manpower increased (17)Orthodontic services better organized (15)Commissioned services increased (4)More general dentists participated in orthodontic
treatments (4)Volume of orthodontic treatment decreased (7)Weakened economic situation (5)Increased need for adults’ dental services (4)Lack of specialist manpower (3)


### 3.2. Specialist Orthodontists’ Views on Orthodontic Care in Health Centres

The  specialist orthodontists proposed that specialists
should not give simple orthodontic treatment but concentrate on treatment
planning, consultation, and difficult treatment. Forty-five respondents (64%) wanted
to change the work division between specialists and general dentists; thirty-three
(47%) wanted to increase the share of general dentists mainly by delegating
simpler treatments to them: treatment with appliances such as quadhelix, headgear,
activator, face mask, and removable appliances. Seventeen respondents (24%) wanted
to decrease the involvement of general dentists in difficult treatments and the
number of treatments started independently, without consultation.Only one specialist orthodontist wanted to decrease
delegation to auxiliaries, while 65 of them wanted to increase delegation by
devolving routine tasks more often. The most common tasks to be delegated were
the taking of impressions (51% of respondents answering this question),
rebonding (50%), setting of bands (50%), health education and motivation (42%),
bonding of brackets (15%), and changing of ligatures and arch wires (8%).Eighty-one percent of specialist orthodontists had made some
changes in their treatment practices during the preceding ten years. The most
frequent changes concerned the application of new treatment techniques (71%),
and of these, the adoption of an eruption guidance appliance was most common (36%).  Secondly, respondents reported changes in the
timing of treatment (54%), with the majority (75%) moving to an earlier
starting age. Thirdly, fourteen respondents were delegating orthodontic tasks
to general dentists or auxiliaries more often.When the specialist orthodontists
were asked to name those features of Finnish orthodontic care they considered
to be of good quality, 55% listed the population-based system in the organization
of orthodontic services, 25% the good professional skills of specialists, and 20%
professional skills in the execution of early treatment.When assessing public orthodontic
care as a whole, the orthodontists complained about the wide variation in the
access to orthodontic treatment and unsatisfactory routines in the treatment
processes. The most frequently mentioned improvement suggestion was an increase
in specialist manpower (Table5).Table 5
Aspects in need of improvement
and suggested tools for improvement according to specialist orthodontists (percentage
of respondents in parenthesis).
Aspects in need of improvement(%)Lack of national guidelines for
orthodontic care40Inefficient routines in
documentation, planning and follow-up of treatments36Insufficient work division in
orthodontic care35Lack of orthodontic skills among
general dentists30Suggested
tools for improvement(%)Increased education of specialist
orthodontists39Additional orthodontic resources
needed for public health services30Better cooperation between central
hospitals and health centres19Remuneration of orthodontic
treatment by sickness insurance or by introducing orthodontic service
vouchers for private services16Both respondent groups stressed the
need for research on treatment outcome and stability of treatment results. The
efficacy of treatment methods was similarly mentioned by both groups, while the
need for studies on cost-effectiveness was especially emphasized by the
orthodontists (Table6).Table 6
Suggestions for subjects for further research
in orthodontics (percentage of respondents in parenthesis).
Suggested subjectChief dental officers (%)Orthodontists (%)Long-term stability of treatment
result1830Effect of timing on treatment
outcome1825Comparison of different treatment
modalities1210Cost-effectiveness analysis1223Need and indications for
orthodontic treatment65Efficacy of eruption guidance
appliances57Efficacy of different orthodontic
treatment practices57


## 3.1. Orthodontic Care in Municipal Health Centres in 2001

Orthodontic services were provided in
all the responding health centres. The volume of orthodontic services was
measured by the percentage of 0–18-year-olds
wearing orthodontic appliances in 2001, the mean percentage being 11.4 (SD 6.4,
range 2–43%). The mean
percentage of children wearing an appliance was the highest in small health
centres with fewer than 10 000 inhabitants. The mean percentage was slightly smaller
in larger centres, but the differences were not statistically significant. The
percentage of orthodontic visits of all dental visits of the 0–18-year-olds was,
on average, 30.7 (SD 10.6, range 2–66% among health
centres), and the size of the health centre was not associated with the ratio
of orthodontic visits (Table1).Table 1
The volume of orthodontic services in
the health centres of different size groups in 2001 measured by the number of 0–18-year-old children
wearing appliances and by the share of orthodontic visits of all visits in the
age group of 0–18-year-olds.
Number of inhabitantsPercentage of 0–18-year-olds wearing an orthodontic appliancePercentage of orthodontic visits of all visits of
0–18-year-oldsmean (SD)mean (SD)Below 10 00013.6 (7.1)30.4 (10.0)10 000–19 99912.8 (6.3)30.7 (14.1)20 000–29 99911.9 (6.0)31.3 (6.0)30 000–50 00010.6 (4.4)32.6 (6.2)Above 50 00010.3 (6.4)30.1 (8.7)A quadhelix was the most frequently
used appliance in primary dentition, followed by an eruption guidance
appliance. A headgear was the most frequently used appliance both in the age
group of 7 to 9 years, and in the age group of 10 to 13 years (Table2).Table 2
The appliances mentioned as the first, second, and
third most frequently used appliance in the age groups 7–9 and 10–13 years.
(a)
First, second, and third most frequently used orthodontic appliances at the age of 7–9 years(N=205)
ApplianceFirstNSecondNThirdNHeadgear915932Quadhelix646432Eruption guidance appliance343541Removable plate648Functional appliance31618(b)
First, second, and third most frequently used orthodontic appliances at the age of 10–13 years(N=204)
ApplianceFirstNSecondNThirdNHeadgear914327Fixed appliance716944Functional appliance165854Eruption guidance appliance131220Quadhelix1277The most frequent way to obtain
orthodontic expertise, used by 74% of health centres, was by making a contract
with a consultant orthodontist. Every fifth health centre had employed salaried
orthodontist manpower. Commissioned services were purchased in 34% of health
centres. The purchasing of commissioned services was most frequent in the small
health centres with fewer than 20 000 inhabitants. Five percent of health
centres did not have any specialist expertise at their disposal. The ways of
obtaining orthodontic expertise in the health centres of different sizes are
given in Table3. Specialist orthodontists’ working time represented 22% of the
total working time spent on orthodontic treatments in all the responding health
centres.Table 3
How orthodontic expertise
is obtained in the health centres of different sizes, measured as the number of
inhabitants in the area.*
Size of health centre as the number of inhabitants (Number of health centres)Own salaried specialistPurchased consultant servicesPurchased commissioned servicesBelow 10 000 (100)2914010 000–19 999
(50)6411520 000–29 999 (22)1111430 000–50 000
(18)1084Above 50 000 (16)1426All
(206)4315369*Some health centres obtain
expert services in several ways.In almost all the health centres (94%),
general dentists treated some of the orthodontic patients. The working
time they spent on orthodontic treatments represented 64% of the total working
time spent on orthodontic care in the health centres.  Delegation of orthodontic tasks to dental
auxiliaries was used in 61% of health centres, and their working time
represented 14% of the total working time spent on orthodontic care in the
health centres.Seventy-four percent of chief dental officers reported major
changes in the organization of orthodontic services during the previous five
years. In thirty-four health centres, major changes had taken place in the
volume of orthodontic services (Table4). Most of these changes concerned
orthodontic specialist services. The number of specialist orthodontists had
increased in twenty-seven and decreased in seven health centres.Table 4
Changes in the volume of orthodontic
services during the previous five years reported by local chief dental officers
(N = 34).
Changes reported (N)Explanations given by respondents (N)Volume of orthodontic treatment increased (27)Specialist manpower increased (17)Orthodontic services better organized (15)Commissioned services increased (4)More general dentists participated in orthodontic
treatments (4)Volume of orthodontic treatment decreased (7)Weakened economic situation (5)Increased need for adults’ dental services (4)Lack of specialist manpower (3)


## 3.2. Specialist Orthodontists’ Views on Orthodontic Care in Health Centres

The  specialist orthodontists proposed that specialists
should not give simple orthodontic treatment but concentrate on treatment
planning, consultation, and difficult treatment. Forty-five respondents (64%) wanted
to change the work division between specialists and general dentists; thirty-three
(47%) wanted to increase the share of general dentists mainly by delegating
simpler treatments to them: treatment with appliances such as quadhelix, headgear,
activator, face mask, and removable appliances. Seventeen respondents (24%) wanted
to decrease the involvement of general dentists in difficult treatments and the
number of treatments started independently, without consultation.Only one specialist orthodontist wanted to decrease
delegation to auxiliaries, while 65 of them wanted to increase delegation by
devolving routine tasks more often. The most common tasks to be delegated were
the taking of impressions (51% of respondents answering this question),
rebonding (50%), setting of bands (50%), health education and motivation (42%),
bonding of brackets (15%), and changing of ligatures and arch wires (8%).Eighty-one percent of specialist orthodontists had made some
changes in their treatment practices during the preceding ten years. The most
frequent changes concerned the application of new treatment techniques (71%),
and of these, the adoption of an eruption guidance appliance was most common (36%).  Secondly, respondents reported changes in the
timing of treatment (54%), with the majority (75%) moving to an earlier
starting age. Thirdly, fourteen respondents were delegating orthodontic tasks
to general dentists or auxiliaries more often.When the specialist orthodontists
were asked to name those features of Finnish orthodontic care they considered
to be of good quality, 55% listed the population-based system in the organization
of orthodontic services, 25% the good professional skills of specialists, and 20%
professional skills in the execution of early treatment.When assessing public orthodontic
care as a whole, the orthodontists complained about the wide variation in the
access to orthodontic treatment and unsatisfactory routines in the treatment
processes. The most frequently mentioned improvement suggestion was an increase
in specialist manpower (Table5).Table 5
Aspects in need of improvement
and suggested tools for improvement according to specialist orthodontists (percentage
of respondents in parenthesis).
Aspects in need of improvement(%)Lack of national guidelines for
orthodontic care40Inefficient routines in
documentation, planning and follow-up of treatments36Insufficient work division in
orthodontic care35Lack of orthodontic skills among
general dentists30Suggested
tools for improvement(%)Increased education of specialist
orthodontists39Additional orthodontic resources
needed for public health services30Better cooperation between central
hospitals and health centres19Remuneration of orthodontic
treatment by sickness insurance or by introducing orthodontic service
vouchers for private services16Both respondent groups stressed the
need for research on treatment outcome and stability of treatment results. The
efficacy of treatment methods was similarly mentioned by both groups, while the
need for studies on cost-effectiveness was especially emphasized by the
orthodontists (Table6).Table 6
Suggestions for subjects for further research
in orthodontics (percentage of respondents in parenthesis).
Suggested subjectChief dental officers (%)Orthodontists (%)Long-term stability of treatment
result1830Effect of timing on treatment
outcome1825Comparison of different treatment
modalities1210Cost-effectiveness analysis1223Need and indications for
orthodontic treatment65Efficacy of eruption guidance
appliances57Efficacy of different orthodontic
treatment practices57


## 4. Discussion

There was a wide variation in the
extent of orthodontic services among Finnish health centres. The variation in
the access and delivery of treatment also seemed to be the main concern among
the orthodontists working in or cooperating with health centres. The economic
depression in the 1990s had not been directly reflected in the extent of orthodontic
services, and more health centres had increased than decreased their services
during the last decade.The earlier survey on public
orthodontic care of children and adolescents in Finnish municipal health
centres made it possible to evaluate the changes in services during the
ten-year period [2]. The overall extent of services had generally increased, but
the 20-fold differences among health centres still prevailed. A new appliance, the
eruption guidance appliance, was introduced during the period. The eruption
guidance appliance seemed to have replaced the use of removable plates and
functional appliances in the early treatment group. Delegation of orthodontic
tasks to auxiliaries had increased, and delegation was widely accepted by the
orthodontists.The information on orthodontic
treatment delivery in health centres was collected retrospectively. The majority
of the nonresponding health centres were smaller ones, which obviously had more
difficulties in collecting the retrospective data. Because this evaluation
concentrated on public services provided in municipal health centres, it was justified
to include only the views of the orthodontists working in or cooperating with
the health centres.The methods of measuring the volume
of orthodontic treatment vary in different countries, and this hampers reliable
comparisons [3, 12, 13]. According to Chestnutt et al. [12], the extent of
orthodontic treatment also increased in Britain between 1993 and 2003. Correspondingly,
we found that the mean percentage of children and adolescents receiving
orthodontic treatment had increased from 7.6% in 1992 to 11.4% in 2001 [2].The average share of orthodontic
visits of all dental visits of children and adolescents had increased slightly
from 26% in 1992 [2] to 30% in this study. An explanation for the increase in
this ratio is the simultaneous decrease in numbers of general dental visits [14].
Furthermore, in 1998, the National Research and Development Centre for Welfare
and Health published a report recommending longer oral examination intervals in
children and adolescents [15]. However, the large variation among health
centres in the share of orthodontic visits (2–66%) cannot be plainly
explained by this change.Most of the changes in providing
orthodontic services were related to the availability of specialist manpower;
an increase in the number of orthodontists was reported more often than a lack
of specialists. The possibilities to organize specialist services seem to
differ between small and large health centres. When compared with the earlier study,
the availability of health centres’ own orthodontic expertise had slightly increased,
as the percentage of health centres employing their own salaried specialist had
increased from 18% to 21% [2]. All municipalities, regardless of their size,
have an equal responsibility to organize treatment even in the most severe
cases. This might be one reason why the percentage of health centres purchasing
commissioned services had increased from 8% in 1992 to 34% in 2001.According to the respondents in the present study, the weakened
economic situation was the most frequent reason for reducing children’s
orthodontic services. The effects of economic restraints on the public
orthodontic services have been evaluated in Denmark and in Sweden [16, 17]. According
to Linder-Aronson et al. [17], the restrictions of orthodontic services
cannot be defended by a decreasing need of treatment.  Actually, the restriction of access to
orthodontic treatment seems to lead to an increased consumption of resources [16].
In Sweden, the economic restraints seemed to decrease the number of treatments
provided by general dentists and the use of appliances demanding good
compliance [18].It has been suggested that the costs
of orthodontic services could be lowered by changes in the division of work and
by delegation of tasks to dental auxiliaries [19]. The delegation of
orthodontic tasks is an acceptable practice in all Nordic countries, but is
applied most widely in Denmark and Sweden. In Sweden, the work division is also
facilitated by the systematic training of orthodontic assistants [20]. In
Finland, the share of health centres applying delegation of orthodontic tasks
to auxiliaries had increased from 28% to 61% from 1991 to 2001 [2]. This
development seemed to be largely accepted among Finnish orthodontists. They
were also interested in devolving simpler orthodontic treatments to general
dentists with the premise that the planning of treatment was carried out by
specialists.The orthodontists were concerned about the great variation
in the delivery of orthodontic care and almost half of them suggested that national
guidelines should be established to reduce this variation. The development of
guidelines has also been suggested earlier as a good tool for reducing
variation in the provision of health services [21, 22]. Guidelines on the screening
of malocclusions and the assessment of treatment need could diminish the
variation in access to and volume of treatment. Furthermore, the inefficient routines
used in the planning and documentation of treatments, which were also mentioned,
could be improved by national guidelines.


## 5. Conclusions

National guidelines and delegation of orthodontic tasks were
suggested as principal tools for reducing the wide variation among the health
centres. The retirement of orthodontists will accelerate in the near future. Thus,
the orthodontists’ suggestion to increase the number of specialist
orthodontists is justified. Additional
resources for orthodontic services should be established without further delay
by organizing local and national training for auxiliary personnel working in
orthodontic teams. Furthermore, development of national guidelines for the orthodontic
treatment process might increase both the uniformity and effectiveness of
treatment.



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*Source: 945074-2009-02-01.xml*