Peninsula Dental Social Enterprise (PDSE) Orthodontic Checklist for Clinics Version 3.0 Date approved: November 2017 Approved by: The Board Review due: November 2018 Policy will be updated as required in response to a change in national policy or evidence-based guideline. Page 1 of 9
Index of Orthodontic Treatment Need (IOTN) The Index of Orthodontic Treatment Need (IOTN) attempts to rank malocclusion in terms of the significance of various occlusal traits for an individual s dental health and perceived aesthetic impairment. It intends to identify those individuals who would most likely benefit from orthodontic treatment. IOTN is the measure used in the UK to assess the need and eligibility of children under 18 years of age, for NHS orthodontic treatment on dental health grounds. NHS orthodontic treatment for adults is not usually available. The British Orthodontic Society believes that if treatment has to be rationed, then the IOTN is an objective and reliable way for specialists to select those children who will benefit most from treatment and is a fair way to prioritise limited NHS resources. Dentists who refer children for orthodontic advice and/or treatment should be aware of the IOTN and how it is used to select which children need and are eligible for NHS orthodontic treatment. Then they can advise their patients and make appropriate referrals. The accurate use of IOTN requires specialist training. The accurate assessment of dental health need for orthodontics should be done by a specialist. The consultation is an opportunity for a thorough check for other abnormalities. Those who do not have a dental need for treatment will have had the reassurance of an expert opinion on their dental development. Page 2 of 9
THE DENTAL HEALTH COMPONENT (DHC) OF THE INDEX OF ORTHODONTIC TREATMENT NEED (IOTN) GRADE 5 (Need treatment) GRADE 3 (Borderline need) 5i 5h 5a Impeded eruption of teeth (except for third molars) due to crowding, displacement, the presence of supernumerary teeth, retained deciduous teeth and any pathological cause. Extensive hypodontia with restorative implications (more than 1 tooth missing in any quadrant) requiring pre-restorative orthodontics. Increased overjet greater than 9mm. 3a 3b 3c Increased overjet greater than 3.5mm but less than or equal to 6mm with incompetent lips. Reverse overjet greater than 1mm but less than or equal to 3.5mm. Anterior or posterior crossbites with greater than 1mm but less than or equal to 2mm discrepancy between retruded contact position and intercuspal position. 5m Reverse overjet greater than 3.5mm with recorded masticatory and speech difficulties. 3d Contact point displacements greater than 2mm but less than or equal to 4mm. 5p Defects of cleft lip and palate and other craniofacial abnormalities. 3e Lateral or anterior open bite greater than 2mm but less than or equal to 4mm. 5s Submerged deciduous teeth. 3f Deep overbite complete on gingival or palatal tissues but no trauma. GRADE 4 (Need treatment) GRADE 2 (Little) 4h Less extensive hypodontia requiring prerestorative orthodontics or orthodontic space closure to obviate the need for a prosthesis. 2a Increased overjet greater than 3.5mm but less than or equal to 6mm with competent lips. 4a Increased overjet greater than 6mm but less than or equal to 9mm. 2b Reverse overjet greater than 0mm but less than or equal to 1mm. 4b 4m 4c Reverse overjet greater than 3.5mm with no masticatory or speech difficulties. Reverse overjet greater than 1mm but less than 3.5mm with recorded masticatory and speech difficulties. Anterior or posterior crossbites with greater than 2mm discrepancy between retruded contact position and intercuspal position. 2c 2d 2e Anterior or posterior crossbite with less than or equal to 1mm discrepancy between retruded contact position and intercuspal position. Contact point displacements greater than 1mm but less than or equal to 2mm. Anterior or posterior openbite greater than 1mm but less than or equal to 2mm. 4l 4d Posterior lingual crossbite with no functional occlusal contact in one or both buccal segments. Severe contact point displacements greater than 4mm. 2f 2g Increased overbite greater than or equal to 3.5mm without gingival contact. Pre-normal or post-normal occlusions with no other anomalies (includes up to half a unit discrepancy). 4e 4f 4t 4x Extreme lateral or anterior open bites greater than 4mm. Increased and complete overbite with gingival or palatal trauma. Partially erupted teeth, tipped and impacted against adjacent teeth. Presence of supernumerary teeth. GRADE 1 (None) 1 Extremely minor malocclusions including contact point displacements less than 1mm. Page 3 of 9
THE AESTHETIC COMPONENT (AC) OF THE INDEX OF ORTHODONTIC TREATMENT NEED (IOTN) The Aesthetic Component is a scale of 10 colour photographs showing different levels of dental attractiveness. The dental attractiveness of prospective patients can be rated with reference to this scale. In the NHS, the AC is used for border-line cases with Grade 3 DHC. If the case has an AC score of greater or equal to 6, NHS treatment is permissible. Page 4 of 9
EXAMPLE OF ORTHODONTIC ASSESSMENT PROFORMA WHICH MAY BE USED AT A SPECIALIST VISIT Patient s name and identifying number SKELETAL PATTERN AP Class I FMPA Average Asymmetry None Class II Reduced Right Class III Increased Left Mild LAFH Average Moderate Reduced Severe Increased SOFT TISSUES Lips Competent Speech Normal Habits None Incompetent Abnormal Past Present Lower lip In front Swallow Normal Below Abnormal Behind TMJ SYMPTOMS TMJ SIGNS INTERARCH RELATIONSHIPS INCISOR RELATIONSHIP OVERBITE Class I Increased Complete to tooth Class II div 1 Average Complete to mucosa Class II div 2 Reduced Incomplete Class III Edge to edge OVERJET mm AOB mm CENTRE LINES Upper Lower ANTERIOR CROSSBITE Yes..No Correct MANDIBULAR Right DISPLACEMENT Yes..No Left.mm.mm CANINES Right Left MOLARS Right Left Class I Class I ½ II ½ II II II ½ III ½ III III III POSTERIOR CROSSBITE MANDIBULAR DISPLACEMENT Page 5 of 9 Yes..No Yes..No
LOWER ARCH INCISORS Average CANINES Right Left Inclination Retroclined Mesial Proclined Upright Distal Crowding Spaced No crowding/ well aligned BUCCAL SEGS Right Left Mild crowding Spaced Moderate crowding Well aligned Severe crowding Mild crowding Moderate crowing Rotations Yes No Severe crowding UPPER ARCH INCISORS Average CANINES Right Left Inclination Retroclined Unerupted palpable Proclined Unerupted not palpable Mesial Crowding Spaced Upright No crowding/ well aligned Distal Mild crowding Moderate crowding BUCCAL SEGS Right Left Severe crowding Spaced Well aligned Rotations Yes No Mild crowding Moderate crowding Diastema Yes No Severe crowding GENERAL DENTAL Teeth present ----------------------------------------------l------------------------------------------------- Oral hygiene Good Fair Poor Trauma/pathology JUSTIFICATION FOR TAKING RADIOGRAPHS RADIOGRAPHS TAKEN AND RELEVANT RADIOGRAPHIC FINDINGS IOTN DHC Aesthetic Not measurable (mixed dentition) OUTCOME OF PATIENT VISIT Page 6 of 9
BASIC ORTHODONTIC ASSESSMENT CHECKLIST THAT YOU MIGHT WANT TO USE IN PRACTICE What is the PATIENT S CONCERN? What is the SKELETAL PATTERN? What is the SOFT TISSUE PATTERN? Are there any FINGER OR THUMB SUCKING HABITS? Are there any TMJ SYMPTOMS OR SIGNS? What is the INCISOR RELATIONSHIP? How big is the OVERJET in millimetres? Is there an ANTERIOR CROSSBITE (& mandibular displacement)? Is the OVERBITE normal, increased or decreased? Are the DENTAL CENTRELINES in the middle of the face? What is the FIRST MOLAR RELATIONSHIP? Are there any POSTERIOR CROSSBITES (and mandibular displacement)? Describe the LOWER ARCH Describe the UPPER ARCH Labial segment Canines Buccal segments Labial segment Canines Buccal segments COUNT THE TEETH Are there any UNERUPTED or ECTOPIC teeth? What is the standard of the ORAL HYGIENE? Is there any DENTAL PATHOLOGY (caries, periodontal disease, trauma)? Do you need a RADIOGRAPH to investigate further? (What does this show?) What is the IOTN for the patient? Do you need to MAKE A REFERRAL? Page 7 of 9
ORTHODONTIC REFERRAL PROCESS The NHS offers children under the age of 18 an orthodontic assessment and treatment if appropriate. Patients with complex malocclusions or with a need for multi-disciplinary care should be referred to a hospital department. All other patients should be referred to a specialist practice. The NHS only offers orthodontic treatment to adults in certain complex cases and these patients should be referred to a hospital orthodontic department for assessment. The majority of adults will need to be referred on a private basis to an orthodontic specialist practice. When making a referral, please make sure the patient knows that a fee will be charged for the orthodontic assessment and for any subsequent treatment. The referral options for orthodontic assessment/treatment: 1 Referral to Hospital Orthodontic Department A referral letter is needed to: Orthodontic Consultant Orthodontic Department Level 07 Derriford Hospital PL6 8DH 01752 432983 Orthodontic Consultant Orthodontic Department Royal Devon and Exeter Hospital Barrack Road Exeter EX2 5DW 01392 411611 Orthodontic Consultant Orthodontic Department Royal Cornwall Hospital (Treliske) Truro Cornwall TR1 3LQ 01872 253980 Page 8 of 9
2 Referral to Orthodontic specialist practice. There are 2 orthodontic referral practices in Plymouth currently accepting NHS patients (under 18) and adults under private contract. These practices require a referral note (kept in Lead s office) and a covering letter. (Plymouth) The Crescent Specialist Dental Centre 2 The Crescent Plymouth PL1 3AB 01752 222444 Plymouth Orthodontics 60 Lower Compton Road Plymouth PL3 5DW 01752 662554 (Truro) Mr Nick Wenger Kernow Health Referral Management Service 1st Floor Cudmore House Treliske Industrial Estate TRURO TR1 3LP (Exeter) Exeter Orthodontic Practice 1 Richmond Road Exeter EX4 4JF 01392 251105 An orthodontic referral letter should include the following information: Patient details and any relevant medical, dental or social history A brief summary of the patient s concerns and your reason for referral A brief description of the malocclusion Information about any teeth of poor prognosis Once the necessary paperwork has been completed and you have explained to your patient that they have been referred for an orthodontic assessment by a specialist, please hand the referral and the covering letter to your Lead Nurse, who will action it. A letter will be returned to you from the Orthodontist once the patient had been seen. This will be reviewed by the Clinical Lead. Reception will then make an appropriate appointment for any necessary treatment to be carried out. Page 9 of 9