Clinical Effectiveness Bulletin - May 2025

April 2020 Number 44

May 2025 Number 54

Clinical Effectiveness Bulletin Clinical Governance Directorate of the British Orthodontic Society

April2020

Clinical Effectiveness Bulletin1

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Director's Remarks Congratulations to Robert Smyth and his editorial team for the Clinical Effectiveness Bulletin. This issue for spring 2025 is number 54 and contains papers looking at the way care is provided for our patients. Papers including how patients come to our attention, how we are paid through coding, how we deal with breakages and unscheduled appointments, empowering patients to have some input into their own care and making every visit to their specialist count. The Bulletin really does help in demonstrating our service is more clinically effective and I strongly recommend it to you.

The British Orthodontic Society (BOS) aims to promote the study and practice of orthodontics.

Alongside this it strives to maintain and to improve professional standards in orthodontics and to encourage research and education in the specialty. It was a pleasure to see many colleagues at the British Orthodontic Conference in Birmingham and to celebrate thirty years since the unification of orthodontic societies in the UK to form the BOS. I know how hard Guy Deeming and the conference committee have worked to put together this excellent conference and to celebrate our achievements as a society.

The governance team have continued to support the BOS with enquiries from the public about the provision of orthodontic care. Although the BOS is not part of the process of making a complaint,

we do occasionally have questions about the care patients are receiving and aim to provide helpful and timely advice. Members of the governance team have also been in contact with the General Dental Council and the Professional Standards Authority on behalf of the Society. The demand for surveys of the BOS membership remains healthy and we will continue to manage this to ensure the voice of our membership is heard but that members are not overwhelmed with requests for their opinion.

When these surveys do appear, please do complete them as they often form part of our next generation’s research and deserve our support. Our publications arm through Sameer Patel continues to update our BOS guidelines, patient information leaflets and digital communication.

I would like to take this opportunity to show my appreciation and to thank Mariyah Nazir, Chair of Audit, Dr Sameer Patel, Chair of Publications and Dr Nicky Stanford, Chair of Ethics for BOS, all of whom play an active part in the Governance Directorate. Finally, once again please do not forget to #KeepBritainSmiling in your own social media.

Or by setting up your own Keep-Smiling page.

Stephen Chadwick Director of Clinical Governance of British Orthodontic Society

4 Clinical Effectiveness Bulletin May 2025

Aims and Scope The British Orthodontic Society Clinical Effectivness Bulletin is an official bi-annual publication of the British Orthodontic Society Clinical Governance Directorate. The primary focus of articles in the Bulletin is the reporting of the quality of orthodontic care and ways to improve it via both clinical audit and effectiveness. The British Orthodontic Society Clinical Effectiveness Bulletin welcomes submissions reporting both these aspects of clinical governance. Clinical audits (in particular multi-cycle audits) and service evaluations would be considered for publication.

All submitted articles undergo peer-review.

Acceptance of articles will be based on the recommendations of the reviewers with the final decision made by the Editor. In addition, submissions will be judged against the following criteria: 1. Does this article add anything new to the existing literature?

2. Does the subject content reflect any relevant national topics?

3. Have the authors implemented a change in clinical practice and assessed the effects? i.e. re-audits

Submission process Submission process for British Orthodontic Society Clinical Effectiveness Bulletin

Articles submitted to the Editor

Articles sent to regional Sub-editors

Articles sent to peer -reviewers (Post-CSST trainees) via Sub-editors

Peer-reviewed articles returned to Editor from Sub-editors with comments/decisions Final decision made by Editor

Provisional article acceptance

Articles returned to authors including: • Amended article • Peer-reviewers checklist with comments/ feedback

Article rejected

Articles returned to authors including: • Amended article • Peer-reviewers checklist with comments/ feedback

Amended articles returned to Editor with 8 weeks for final editorial changes

Final acceptance email sent to authors prior to publication

May 2025 Clinical Effectiveness Bulletin 5

Editor's Remarks Welcome to the spring edition of the Clinical Effectiveness Bulletin.

Anyone interested in becoming a reviewer for the Bulletin should approach the Sub-Editor for their region; South East: Mr Stuart Yeaton, s.yeaton@nhs.net South West: Ms Lizzie Crawford, elizabeth.crawford3@wales.nhs.uk Northern: Ms Sarah Germain, sarah.germain@ncic.nhs.uk Scotland/Ireland: Mr Colin Ritchie, colin.ritchie2@nhs.scot This issue presents a variety of high-quality articles and I would like to thank the contributors and peer reviewers for their efforts. Finally, a special thanks also go to Dr Stephen Chadwick, Mr Chris Baker and all the team for their support in producing this issue of the CEB. I hope you enjoy reading the articles in this issue.

Robert Smyth Editor, BOS Clinical Effectiveness Bulletin

Adverse Incident Reports Since the last edition report (Autumn 2024) there have been 0 incidents reported to the Society through our confidential reporting system.

Farooq Ahmed Adverse Incidents Officer British Orthodontic Society

Reviewers 2024 Sobie Akram Sasha Brannen Amardeep Dhadwal Kyle Durman Aled Griffiths Claudy Henein Olivia Johnson-King Francine Jones George Jones

6 Clinical Effectiveness Bulletin May 2025

Timothy Jones Jen Jopson Safoora Keshtgar Nathan Nagar Kishan Patel Nirmal Shah Dharmika Tailor Nicola Wade Carrie Whyte

Contents

Quality of referrals for management of ectopic maxillary canines: A fourth cycle audit and associated quality improvement project.

L Roocroft, M Storey Missed orthodontic appointments: A re-audit and focus on children and young people in care.

R Hazar, S Germain Staff education and awareness of e-cigarette use and orthodontics: A quality improvement project.

J Bell, S Germain Accuracy of activity coding in orthodontics: A 2-cycle audit H Quach, S Radia, L Davenport-Jones A re-audit of the rate of unscheduled orthodontic appointments at Chesterfield Royal Hospital.

Z Kassir, J Sandler Going the distance: Comparative analysis of a dramatic change in protocol for patient attendance at Cleft Lip & Palate MDT clinics.

S Daley, S Brannen, L Burbridge, R Mattick

Recycling orthodontic impression trays: A sustainable improvement.

K A Carney, R Bissett, E Chalmers, C Tothill Magnetic resonance imaging and orthodontics: An audit of clinician knowledge and experiences.

D Pathak, F S Ryan Empowering people: Patient initiated follow up in orthodontics.

N Hayek, E Watt, F S Ryan A two-cycle audit of periodontal assessment and appropriate management within the orthodontic department at a UK teaching hospital.

K Nandhra, H Jeremiah, N Wright ‘Making Every Contact Count in Orthodontics’: A regional quality improvement project.

N Caratela, S Higgins, S Kotecha The effects of the COVID-19 pandemic on orthodontic treatment in a Dental Hospital and a District General Hospital: A service evaluation.

SJ Campbell, K Smorthit, N Mandall, C Bates

May 2025 Clinical Effectiveness Bulletin 7

Quality of referrals for management of ectopic maxillary canines: A fourth cycle audit and associated quality improvement project Lucy Roocroft (DCT) and Madeleine Storey (Consultant) University Dental Hospital of Manchester, Manchester Background/Rationale The maxillary canine typically erupts between ages 10-12. The reported incidence of ectopic maxillary canines is 1-2%, and, of this, 61% are displaced palatally1,2.

The exact aetiology of ectopic maxillary canines is unknown, however there are several factors linked to canines straying from their normal path of eruption. This includes hard tissue obstruction, local pathology, disturbance of normal incisor development (for example, diminutive, peg or absent lateral incisors) and genetics3,⁴.

Risks of canine impaction include migration of adjacent teeth resulting in loss of arch space, cyst formation, ankylosis, as well as spacing and centreline shifts. Delays in detection, referral and subsequent management can not only reduce the chance of success but can also result in challenges in treatment planning, risk of early loss of poor prognosis teeth and future restorative burden⁵.

Timely detection and further investigations, such as radiographs should be undertaken by clinicians to localise the canine’s position and identify a requirement for interceptive treatment or referral.

Four cycles of data were collected between the years of 2015 to 2023 with subsequent action plans between cycles. A quality improvement project (QIP) was initiated between cycles 3 and 4, with the aim to improve dental foundation trainees (DFTs) understanding of maxillary canine ectopia and the referral process.

Aims and Objectives The primary aim was to assess the age of patients at time of referral for assessment of ectopic maxillary canines. Secondary to this, we wanted to evaluate the quality of the referrals received, analysing the availability and appropriateness of radiographs submitted and whether referrals coincided with diagnosis of maxillary canine ectopia. Additionally, we assessed whether patients had radiographic evidence of pathology at their orthodontic new patient assessment and what treatment was selected at this consultation.

Standards/guidelines/evidence base The Royal College of Surgeons guidelines, ‘Management of the Palatally Ectopic Maxillary Canine’ and the British Orthodontic Society (BOS) provide clear guidance on the diagnosis and management of impacted maxillary canines⁶.

Clinicians are advised to suspect maxillary canine ectopia if buccal palpation is unsuccessful by ages 10-11 years, if palpation indicates an asymmetrical eruption pattern or the position of adjacent teeth implies a malposition of the permanent canine.

Appropriate radiographs must be taken and prompt referral for orthodontic assessment and intervention.

8 Clinical Effectiveness Bulletin May 2025

Standards for this project were adopted as follows: 100% of referrals for ectopic canines should be received for orthodontic assessment between the ages of 10-12 years of age. 100% of referrals for ectopic canines should have the appropriate accompanying radiographs of good diagnostic quality.

Sample and data source Retrospective case note analysis from all new patient consultation clinics attending the orthodontic department at the University of Manchester Dental Hospital over a set two-month period of October-November. Cycles were over 2015 (cycle 1 with sample size of 199 referrals), 2019 (cycle 2 with sample size of 182), 2021 (cycle 3 with a sample size of 120) and 2023 (cycle 4 with a sample size of 186).

Those patients referred specifically for canines or hypodontia were further filtered using the Greater Manchester “Orthodontics Assessment and Treatment Form”. Each referral was closely analysed in conjunction with the clinical examination record to filter those with true maxillary impacted canines.

Audit type A retrospective four-cycle audit.

Methodology New patient consultation notes were analysed using a standardised data collection table.

Information was collected using the Hospital Trust’s electronic record keeping system, Salud and HIVE. Patients referred specifically for ectopic or impacted canines were explored in detail to gather further information: Reason for referral, age at referral, accompanying radiographs (quality and appropriateness), presence of pathology and subsequent management agreed at new patient consultation. An appropriate radiograph was deemed to be either an OPG, periapical or upper standard occlusal. Bitewings were considered inappropriate as they would be unlikely to show the canine position or any associated pathology.

Management was categorised into no treatment, monitoring the unerupted canine, interceptive extraction of the primary predecessor, exposure of the permanent canine, or surgical removal of the canine.

Findings Results of all cycles are summarised in figures 1 and 2.

Cycle 1 findings (2015) During this cycle, 39 patients were found to have ectopic maxillary canines within the timeframe assessed. Compliance with standard 1 was very limited with only 44% (n=17) of patients being referred between the ages of 10-12 years.

Compliance with standard 2 was also very limited with only 44% (n=17) having appropriate accompanying radiographs. Audit results were disseminated at regional audit and clinical effectiveness days across Greater Manchester to educate referrers and improve compliance.

Cycle 2 findings (2019) 21 patients were referred for ectopic maxillary canines over the 2-month data collection period.

This second cycle showed a further decrease in compliance of for standard 1, with only 29% (n=6) of patients being referred at the appropriate age.

However, an improvement in compliance with standard 2 was noted with 67% (n=14) of referrals containing appropriate radiographs. A poster was subsequently developed and disseminated to aid referral decisions.

Cycle 3 findings (2021) 20 patient referrals were found to have ectopic maxillary canines. This cycle showed a further decrease in compliance with standard 1, with only 50% (n=10) of patients being referred between the ages of 10-12 years. However, a further increase in compliance with standard 2 was noted with 70% (n=14) of referrals containing appropriate radiographs.

A QIP was then initiated, involving development and delivery of study days to Dental Foundation Trainees (DFTs) across Greater Manchester with the aim of increasing awareness of the importance of the timely referrals. Topics covered included investigation of ectopic maxillary canines, IOTN and orthodontic referral quality. A pre and post survey was carried out to assess knowledge of DFTs (figure 3). This showed an improvement in confidence and understanding.

Cycle 4 findings This most recent cycle was carried out in 2023. 26 patient referrals were found to have a diagnosis of ectopic maxillary canines.

Disappointingly, a further decrease in compliance with standard 1 was reported with only 35% (n=9) of patients being referred at the appropriate age.

However, compliance with standard 2 had increased markedly up to 95% (n=24).

May 2025 Clinical Effectiveness Bulletin 9

100

92

90 80

70

67

70 60 50

44

50

44

40 30 20

35

29 20

17

12

14

10 0

Cycle 1

Cycle 2

Cycle 3

Ectopic Maxillary Canines within sample

Cycle 4

Standard 1

Standard 2

Figure 1: Chart showing audit cycle 1,2,3 and 4 compliances (%) with standards 1 and 2, along with percentage of true ectopic maxillary canine referrals found within each sample.

Pathology evidence in referral radiographs Pathology present in appropriate

Cycle 1

Cycle 2

Cycle 3

radiographs

(n=17)

(n=14)

(n=14)

Non present radiographically

65% (n=11)

79% (n=11)

93% (n=13)

50% (n=12)

Root resorption of lateral incisor

12% (n=2)

14% (n=2)

7% (n=1)

25% (n=6)

23% (n=4)

7% (n=1)

0

25% (n=6)

Cycle 1

Cycle 2

Cycle 3

Cycle 4 (n=26)

(n=39)

(n=21)

(n=19)*

No treatment

26% (n=10)

14% (n=3)

5% (n=1)

8% (n=2)

Review

10% (n=4)

14% (n=3)

32% (n=6)

4% (n=1)

Interceptive extraction of the

15% (n=6)

24% (n=5)

21% (n=4)

4% (n=1)

41% (n=16)

19% (n=4)

21% (n=4)

42% (n=11)

8% (n=3)

29% (n=6)

21% (n=4)

42% (n=11)

Cycle 4 (n=24)

teeth Follicular enlargement of canine

Management agreed at initial consultation Treatment decided

primary canine Surgical exposure of the ectopic permanent canine Surgical removal of the ectopic permanent canine

Figure 2: Table showing the types of pathology evident in referral radiographs and management agreed at orthodontic new patient consultation, across cycles 1, 2, 3 and 4. (*) 19 patients out of the 20 analysed attended their new patient consultation and so one patient had not yet had treatment determined at time of data collection.

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Figure 3: DFT Survey completed before and after attendance of the Orthodontic study day. Data from this was then analysed, showing an increase in knowledge regarding orthodontic assessment and the referral process.

Observations Results from this 4-cycle audit project have demonstrated an overall decrease in compliance for standard 1: the timely referral of ectopic maxillary canines. Difficulty in achieving gradual improvement across cycles could be associated with lack of regular dental assessment and palpation of maxillary canines in general practice, which may itself be a result of the challenges faced by the public accessing NHS funded dental care.

Ultimately, this is a difficult factor to control, particularly with current workforce development issues. During cycle 4, it was noted that 2 of the 65% (n=17) of patients referred after the age of 12, were from internal departments at Manchester Dental Hospital. This further supports the above hypothesis of fewer patients being registered for regular assessment with GDPs, and more accessing secondary care dental services as a first time visit to the dentist.

A retrospective audit by the orthodontic department at Queen Elizabeth Hospital, Kings Lynn, assessed patient records from new orthodontic assessments⁷. True ectopic maxillary canine referrals were analysed. Results showed many referrals didn't meet RCS standards, with 51% of patients referred later than recommended, at age 13 or older. This closely mirrors findings from the Manchester Dental Hospital audit.

Reassuringly, however, there has been a significant increase in compliance for standard 2 across all four audit cycles of +42%. Referrer’s ability and awareness to provide appropriate accompanying radiographic assessment has considerably improved through this project.

Following the 3rd audit cycle, an improvement project was initiated, working to provide regular deanery study days to DFTs in Greater Manchester

May 2025 Clinical Effectiveness Bulletin 11

on IOTN awareness, ectopic maxillary canine management and referral quality. It is possible that this has had a positive effect at improving knowledge of aspiring GDPs in the region.

Nevertheless, these study events work to target newly qualified dentists only. It can be challenging to target teaching to more experienced cohorts who may access or obtain their CPD differently.

Improved communication is needed between orthodontic services, referral centres and dental practitioners. Collaborating with managed clinical networks and local dental networks may help address referral barriers. Educating on the importance of timely detection and referral of impacted canines could prevent treatment delays.

Recommendations The results of the audit were discussed at multiple regional clinical audit meetings in the Northwest The following recommendations were made: 1. Further education of GDPs in Greater Manchester on importance of referring impacted maxillary canine teeth between the ages of 10-12. We plan to continue delivery of DFT orthodontic study days, with the hope to educate possible aspiring GDPs in the Greater Manchester region.

2. Continued dissemination of findings, and liaison with local dental committees, managed clinical networks to improve referral proformas, reminding practitioners of the importance of including appropriate radiographic assessment.

3. No further audit cycles are planned at present.

Project involvement Lucy Roocroft (Project lead, project design, data collection, data analysis and presentation) Madeleine Storey (Project design and supervision)

12 Clinical Effectiveness Bulletin May 2025

References 1. Ericson S, Kurol J. Radiographic assessment of maxillary canine eruption in children with clinical signs of eruption disturbance. The European Journal of Orthodontics.

1986 Aug 1;8(3):133-40.

2. Stivaros N, Mandall NA. Radiographic factors affecting the management of impacted upper permanent canines. Journal of Orthodontics.

2000 Jun;27(2):169-73.

3. Becker A. In defence of the guidance theory of palatal canine displacement.

The Angle Orthodontist. 1995 Jan 1;65(2):95-8 4. Peck S. The palatally displaced canine as a dental anomaly of genetic origin.

Angle Orthod. 1995; 65:95-102.

5. Seager L, Shah J, Burke T. The Management and ‘Fate’ of Palatally Ectopic Maxillary Canines.

Dental Update. 2020 Feb 2;47(2):153-61.

6. Husain J, Burden D, McSherry P, Hania M. Management of the Palatally Ectopic Maxillary Canine. National Clinical Guidelines, Faculty of Dental Surgery, Royal College of Surgeons of England. 2022.

7. Aiyegbusi O, Nandra S. Clinical audit: the importance of early detection and referral of impacted maxillary canines. Dental Update. 2019 May 2;46(5):488-95

Missed orthodontic appointments: A re-audit and focus on children and young people in care Roya Hazara (ST) and Sarah Germain (Consultant) Cumberland Infirmary, Carlisle

Background/Rationale Children should not be accountable for missed appointments. It is the duty of their parents and carers to bring them to medical appointments. Children and young people are categorised as those from birth to their 18th birthday1. To protect and safeguard this group, Was Not Brought – Children and Young People pathway (WNB-CYP) was introduced in 2015 by the British Dental Association (BDA)2.

Documenting ‘Was Not Brought’ instead of ‘Did Not Attend’ enables us to see the situation from the child’s perspective, to assess the child’s wellbeing and identify what support the child needs and whether a referral to support services is required. Missed appointments and dental neglect are the most common reasons for dentists to make a safeguarding referral3.

Previous audit cycle findings led to implementation of the WNB-CYP pathway in the department to benefit children receiving orthodontic assessment or treatment⁴. Earlier parent/patient contact may reduce the number of missed appointments and the time interval between appointments. It was noted since the initial audit rounds that the rate of missed appointments was higher for children under care of the local authority (CLA); further investigation and action was required in relationship to this vulnerable patient group.

Aims and Objectives The primary aim of this audit is to ensure all missed appointments are recorded as WNB and when an appointment is missed the subsequent management is in line with our WNB policy. The secondary aim was to compare the rate of missed appointments for children who are CLA and to other departments in the Trust.

Missed appointments in CLA patients were identified using PAS over a period of 12 months, January 2022 to January 2023. The Trust average WNB rate was provided by the Trust data analyst for the same 12-month period.

Standards/guidelines/evidence base In line with BDA guidance all missed appointments in CYP should be recorded as Was Not Brought (WNB) (100%)2. All missed appointments should be appropriately followed up in line with departmental policy (100%) or if policy is not followed, appropriate justification should be documented in the clinical notes. No child should be lost to follow up in active treatment (0%). The rate of missed appointments should be no higher for CLA patients or the Trust average.

Audit type A retrospective audit.

Sample and data source Missed orthodontic appointments were identified using the Trust patient administration system (PAS) from 1st November to 30th November 2022. All planned orthodontic appointments were included for new, review and treatment appointments for all CYP.

Patients over the age of 18 years were excluded from all samples.

Methodology The rate of missed appointments was calculated by the trust data analyst and provided as a percentage.

WNB rate =

Number of WNB appointments

Number of WNBs+Number of attendances

𝑋𝑋 100

Cancelled appointments were included in the number of planned attendances. The orthodontic overall WNB rate was calculated for November 2022. The CLA and Trust average were taken from the data for the whole year of 2022.

Notes were requested for all the children and young people who missed appointments in orthodontics in November 2022. These were analysed against the WNB-CYP pathway (Figure 1) for management and compliance.

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Figure 1: Was Not Brought pathway (BDA)

Figure 1: Was Not Brought pathway (BDA)

Findings In the month of November 2022 there were a total of 1335 scheduled orthodontic appointments for those under 18 years of age of which 61 were classified as ‘was not brought’.

The rate of WNB appointments is compared in Figure 2. There was an improvement in WNB rate overall from 7.5% to 4.5% between 2019 and 2022.

This WNB rate was lower than the trust average WNB rate at 13% and orthodontic CLA population of 17%.

4.5% of orthodontic CYP patients were not brought to their appointment. 100% of the missed appointments were documented in the notes, only 14 Clinical Effectiveness Bulletin May 2025

86% of the missed appointments were documented as ‘Was Not Brought’.

14 out of a total of 81 (17%) planned attendances for children and young people who were in CLA did not attend and were classified as ‘Was Not Brought’.

Was Not Brought Rate (%) Trust 2022

Orthodontic CLA 2022

Orthodontic Nov 2022 (2nd cycle)

Orthodontic Nov 2019 (1st cycle)

0.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

14.0%

16.0%

18.0%

Figure 2: Rate of missed appointments for Orthodontic and Trust patients Observations There was an improvement in the WNB rate between this audit cycle and the previous rounds⁴.

This was felt to be related to the introduction of a policy to ensure patients in treatment left with a suitable appointment at the end of their visit.

This avoided any patients being lost to follow up and ensures patients are aware of their next appointment in case there is any delay to receiving their appointment confirmation letter.

The introduction of a WNB-CYP pathway improved consistency in management; this was followed for all missed appointments and no patients in the cohort were lost to follow up.

86% of missed appointments were documented as WNB. This is an improvement from 0% in the initial audit cycle in 2019 as a result of increasing awareness of WNB-CYP policy and terminology.

There is still room for improvement and further data analysis of those in the older cohort of 16-17 years to see if this subset is more frequently mis-recorded would be helpful alongside further staff training.

The WNB rate for CYP who are in the Care of the Local Authority (CLA) is higher than both orthodontic and trust patients in general.

Additional actions were undertaken for this group of patients following meeting with the trust CLA

safeguarding lead. The orthodontic secretarial team were given access to an administrative system (Rio) that allowed contact directly with foster placements. When a child was identified as CLA from PAS rather than an appointment letter being sent, telephone contact was made to confirm attendance. Local CLA safeguarding leads are now also copied into any appropriate orthodontic correspondence to ensure they are aware of both missed appointments and ongoing care needs.

The audit findings have also been discussed at the Trust Health Improvement Group that seeks to address health inequalities. WNB for CYP is major focus of the group’s work which now has orthodontic representation Recommendations 1. To continue using WNB pathway policy to record missed appointments for children under 18 years old and those under the care of local authority.

2. A pathway for CLA CYP has been developed with the safeguarding team to reduce missed appointments rates in this patient group.

3. Further training will be provided for regular staff in the department in correct use of WNB pathway.

May 2025 Clinical Effectiveness Bulletin 15

Project involvement Roya Hazara (Data collection and presentation, manuscript draft).

Sarah Germain (Design, project supervisor and approval of manuscript) References 1. General Medical Council, Professional Standards: Guidance for all doctors 2. BDA Implementing ‘Was Not Brought’ in your practice document: https://bda.org/advice/ Documents/WNB-implementation-guide-AW.pdf 3. BDA, 2020. IMPLEMENTING - ‘Was Not Brought’ in your practice - How to use this pathway: British Dental Association. United Kingdom. Retrieved from https://policycommons.net/ artifacts/1660207/implementing/2391857/ on 29 Nov 2023. CID: 20.500.12592/4fnxkn.

4. Fenton G, S Germain. Clinical audit of missed appointments in a hospital orthodontic service.

CEB, 2021 (41), 55-57

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Staff education and awareness of e-cigarette use and orthodontics: A quality improvement project Joseph Bell (ST) and Sarah Germain (Consultant) North Cumbria Integrated Care NHS Foundation Trust

Background/Rationale Electronic cigarettes (EC) have been available in the United Kingdom for over 15 years1. In 2023, 18% of 18-year-olds were EC users in England2 and usage more than once a week in 11–17-year-olds has increased from 1.2% in 2021 to 3.7%. The recent increase in use by 11- to 17-yearolds has sparked concerns regarding its potential impact on oral and overall health3.

Current evidence suggests that EC use is significantly less harmful than tobacco smoking, but not risk free⁴. However, EC use in a young person who is a non-smoker, may cause: unnecessary addiction, disruption to education, costs, environmental impact, and general health impacts, such as lung damage or harm to the developing brain⁵. Moreover, literature suggests potential risks associated with orthodontics and oral health including increased risk of caries, adverse effect impact on orthodontic tooth movements, implications for surgical outcomes and staining⁵.

Given the evolving landscape and the lack of conclusive evidence, there is a need to assess and address the implications of EC use on orthodontic care. This quality improvement project aims to assess the orthodontic team’s knowledge and identify areas for further education. Ultimately this will enhance patient care.

Aims and Objectives Aim: To assess and enhance the orthodontic team's knowledge and understanding of e-cigarettes and vaping.

Objectives: The objectives are to conduct a pre-teaching knowledge-based assessment to establish the baseline understanding of e-cigarettes among orthodontic team members, facilitate a teaching session on e-cigarettes aimed at improving knowledge and awareness, and administer a post-teaching knowledge-based assessment to evaluate the effectiveness of the teaching session in enhancing understanding among orthodontic team members.

Standards/guidelines/evidence base Staff should have knowledge of e-cigarettes and the impact on oral health and orthodontic care as evidence by a score of over 80% in the MCQ assessment.

The 80% standard was agreed as a commonly used standard in educational assessments and audits to ensure a high level of compliance or understanding among participants.

Sample and data source The participants included 12 orthodontic team members who were attending the staff meeting on the 6th of February 2024. All were given an MCQ on e-cigarettes in relation to oral care and orthodontics before and after a bespoke training session.

The inclusion criteria encompassed all orthodontic staff members. Participants included clerical staff, nurses, therapists, registrars, and consultants. The meeting served as the platform for gathering data pertinent to the clinical audit.

Audit type This is a prospective audit relating to a quality improvement project delivering education on e-cigarettes and orthodontics.

Methodology The QIP project team consisted of one orthodontic consultant and one orthodontic specialist registrar. The team collaborated to develop a knowledge-based assessment to assess staff knowledge regarding EC usage and its impact on orthodontic treatment. The assessment tool was made up of 15 questions with content relating to ECs. Figure 1 provides a selection of example questions from each theme—Trends and Statistics, May 2025 Clinical Effectiveness Bulletin 17

General Knowledge, General Health, and Orthodontic Health—along with their corresponding answer options. The rightmost column links each question to the specific educational content or resources used to deliver the relevant information during the presentation or learning module. This tool was piloted to ensure its reliability and validity.

Theme

Teaching in EC was delivered during a clinical governance meeting. Staff members were asked to complete the knowledge assessment tool pre and post educational teaching presentation. This evaluated any changes in knowledge and understanding.

The data obtained from the assessments were entered and analysed using Microsoft Excel.

Example Question In Cumbria, what percentage of secondary school pupils in Years 8 and 10 reported trying vaping? (Circle Best Answer)

Example Answer

What is the primary purpose of electronic cigarettes?

(Circle Best Answer)

a. To produce water vapor b. To burn tobacco c. To inhale nicotine in vapor form d. To release harmful chemicals in the air

Delivered in the presentation slide: ‘What is ’vaping’?’

How does nicotine in ecigarettes impact the developing adolescent brain? (Circle Best Answer) Orthodontic What oral health Health risks are associated with e-cigarettes?

(Circle all correct answers)

a. Enhances cognitive functions b. Increases brain fog c. Improves mood stability d. Increases attention span

Delivered in the presentation slide: Impact of e-cigarettes on general health.

a. Reduced periodontal health b. Increased risk of oral lesions c. Increased risk of dryness and bad breath d. Increased enamel hardness

Delivered in the presentation slides: Potential impact of ecigarette usage on oral health. Evidence from extensive literature search.

Trends and statistics

General Knowledge

General Health

a. 17% b. 24% c. 33% d. 41%

Link to education delivered Taken from Cumbria Children and Young People Survey developed by the Schools Health Education Unit (SHEU) in partnership with Cumbria County Council.

Figure 1: Example MCQ Questions by Theme with Links to Education Delivered

18 Clinical Effectiveness Bulletin May 2025

Findings Overall, the QIP findings met the standard required of a pass rate >80% post educational intervention.

The results of the assessments showed that the overall pass rate increased from 55% pre-teaching to 86% post-teaching. The breakdown for each staff group and different themes are presented in Figure 1.

Pre – Teaching: Pass % Overall

Staff Cohort Orthodontic Consultant

Post – Teaching: Pass % 55

Pre – Teaching: Pass %

86

show an improvement in score pre and post teaching. The themes addressed the key issues relating to EC use and its potential harmful outcomes. Given the typical young patient population we see in orthodontics, it is important all team members are aware of the potential risks associated with EC usage in young people in addition to potential oral and general health risks and risks associated with orthodontic treatment.

Likewise, it is important staff understand the laws and regulations relating to EC usage in young people.

Post – Teaching: Pass % 66.5

100

Orthodontic Nurse

54

84

Orthodontic Therapist

53

73

The questions based on general health showed the smallest change however, they had an overall 46 93 Orthodontic Registrar high pass rate pre and post teaching. The 56.5 80 Orthodontic Secretary questions which included statistics showed the Theme Pre – Teaching: Pass % Post – Teaching: Pass % largest improvement. This is to be expected as 25 94 Trends and statistics the correct statistics were highlighted in the 71 100 General Knowledge 78 81 General Health presentation. This shows participants were 57 79 Orthodontic Health engaged in the teaching presentation. The Figure 2: Comparison of Pre- and Post-Teaching Pass questions based on orthodontic health did not meet the set standard of >80% pass. The questions Percentages Across Staff Cohorts and Themes were challenging as it was expected all team members to have an initial increased level of knowledge with orthodontic related health Observations questions The QIP shows a significant improvement in knowledge pre and post teaching with the MCQ The current evidence base for EC risks is of weak score increasing from 54% to 86% respectively quality however, potential risks have been showing a good standard of knowledge of the highlighted. The evidence is greater for risks wider orthodontic team. This meets the standard associated with a young person who starts using set for the QIP. The methodology provides a EC but has never smoked. The medical history form systematic approach to assessing staff knowledge will be updated to include EC and cigarette use. It through a pre- and post-education assessment is imperative all team members are informed, have process. This allows for the replication of the QIP a good understanding and knowledge of EC usage, by other healthcare institutions or professionals. so they can discuss the potential risks and encourage reducing and ideally eliminating the The QIP shows an improvement for each staff use of EC in young people. cohorts’ knowledge on EC use. All individual staff groups achieved the standard set of >80% apart from the Orthodontic Therapists with a final pass Recommendations score of 73%. It is important all team members 1. Inform orthodontic team of audit results. have a good knowledge and understanding of 2. Update and repeat teaching as new literature the potential risks of EC use. Further teaching will develops. be provided to ensure all team members have the 3. Repeat QIP in 12 months to reassess staff required understanding. knowledge and understanding of EC usage.

4.

Continue to educate patients on the potential The questions were designated themes including risks associated with EC usage. trends and statistics, general health, orthodontic 5.

Amend medical history questionnaire to health and general knowledge of EC. All themes include use of e-cigarettes as well as smoking

May 2025 Clinical Effectiveness Bulletin 19

Project involvement Joseph Bell Sarah Germain References 1. The Tobacco and Related Products Regulation 2016. Available at: www.legislation.gov.uk/ uksi/2016/507/contents/made (accessed June 2024).

2. Discover major findings relating to smoking in England. Available at: https://smokinginengland. info/graphs/ monthly-tracking-kpi (accessed June 2024).

3. Action on smoking and health. Use of e-cigarettes among young people in Great Britain. 2023.

Available at: https://ash.org.uk/resources/view/ use-of-e-cigarettes-among-young-people-ingreat-britain (accessed June 2024).

4. Holliday R, Chaffee BW, Jakubovics NS, Kist R, Preshaw PM. Electronic cigarettes and oral health.

Journal of dental research.

2021 Aug;100(9):906-13 5. Banks E,Yazidjoglou A, Brown S et al. Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence.

Med J Aust 2023; 218: 267–275. https://doi. org/10.5694/mja2.51890.

20 Clinical Effectiveness Bulletin May 2025

Accuracy of activity coding in orthodontics: A 2-cycle audit Henry Quach (ST), Sapna Radia (Consultant) and Lucy Davenport-Jones (Consultant) St. George’s Hospital, London Background/Rationale Activity coding is the process of recording the activity that NHS services provide. Using the OPCS classification1, orthodontic procedures have previously been poorly defined with reliance on non-specific codes2. Guidance by the British Orthodontic Society3 has helped hospital orthodontic teams improve their understanding and accuracy of activity coding. The Payment

by Results system⁴ is directly linked to activity coding and determines the income of trusts. Therefore, the need for full and accurate coding is crucial to service delivery, resource management and clinical governance. The coding data is also looked at by GIRFT for data analysis and opportunities for improvement.

Aims and Objectives Aims

Audit type Two-cycle retrospective audit.

1. To examine whether orthodontic procedures are being correctly coded.

Methodology Electronic patient records (Cerner Powerchart) were reviewed to assess the accuracy of activity coding.

The codes of all procedures carried out and any missing codes were recorded for each attendance.

This was cross-checked with the codes submitted on outcome forms to determine if the attendance was correctly coded. Data was recorded and analysed on Microsoft Excel.

Objectives 1. Retrospectively review patient records to assess the current accuracy of coding.

2. Identify areas requiring improvement and implement changes to improve the accuracy of orthodontic activity coding.

Standards/guidelines/evidence base A standard of 90% accurate selection of orthodontic procedures was set. The 90% standard was agreed based on previously published audit projects relating to activity coding in orthodontics⁵. The guidance document used was ‘Activity Coding in Orthodontics, Information for Secondary Care Trusts’3 published by GIRFT, BOS and RCS England in 2020 and updated in 2023.

Sample and data source Data for all new and follow-up orthodontic attendances in September 2022 (cycle 1) and November 2023 (cycle 2) was provided by the trust finance team. This included the submitted procedure codes (if recorded), the HRG code, the tariff value and the actual value multiplied by the MFF. Attendances with no codes recorded were marked as ‘null’. The role/grade of the clinician submitting activity codes was not recorded.

Findings Cycle 1: Total of 429 patient attendances in September 2022. 5% (n=21) null due to no code recorded. 5% (n=22) excluded due to no notes.

Out of 386 included attendances, 61% (n=235) were correctly coded. 39% (n=151) were incorrectly coded.

Cycle 2: Total of 474 patient attendances in November 2023. 5% (n=25) null due to no code recorded. Out of 449 included attendances, 84% (n=375) were correctly coded. 16% (n=74) were incorrectly coded.

The financial loss due to inaccurate coding was found to be £3214.23 in cycle 1 and £2006.89 in cycle 2.

An improvement of 23% coding accuracy was noted between cycles 1 & 2. However, the accuracy of 84% in cycle 2 did not meet the set standard of 90% accuracy.

May 2025 Clinical Effectiveness Bulletin 21

approval and distribution (figure 3). Collaboration with the coding team was an important aspect of ensuring the form was accurate and user-friendly⁷.

Cycle 1

151 (39%) 235 (61%)

Correct

Incorrect

Figure 1: Results of cycle 1

Cycle 2 74 (16%)

375 (84%) Correct

Incorrect

Figure 2: Results of cycle 2 Observations This audit clearly demonstrates the financial of good coding practice. Numerous studies have previously shown how suboptimal coding practices can lead to financial loss⁶.

The department lacked a coding proforma that was specific to orthodontics. Clinicians previously used several different coding lists which were outdated, missing new codes and included non-orthodontic codes. It has been shown that a well-designed proforma as well as ongoing quality assurance programs can improve the accuracy of activity coding⁷.

A new coding proforma was designed in conjunction with the hospital coding team before 22 Clinical Effectiveness Bulletin May 2025

The new proforma was specific to the workload of the department and laid out in logical sections: assessment, records, treatment (start, end, finish), functional, retention and miscellaneous. These were displayed beside the computer screen at each dental unit.

The results were presented at local and regional clinical governance meetings. Training for existing staff was organised and activity coding included in the local induction.

Key findings in relation to coding errors included the X62.1 code (assessment by a uni-professional team) for new attendances. This code is automatically applied to all non-multidisciplinary attendances and therefore does not need to be recorded. It was advised to use the F43.9 (examination of mouth) code instead.

Taking of radiographs was often coded for radiographs to be taken in the radiology department. Radiographs should only be coded if they were taken within the department.

Therefore, these codes were removed from the proforma as none are taken by the orthodontic team.

Clinicians were asked to record all provided procedures to maximise recorded activity. This ensures that the highest tariff code is not missed.

For example, repositioning a bracket would typically involve four codes: F15.7 (debonding of orthodontic bracket), F16.7 (polishing teeth), F15.2 (fitting of orthodontic bracket) and F15.5 (adjustment of orthodontic device). Of these codes, F15.2 attracts the highest tariff, and bracket repositioning was often recorded as simply F15.5 prior to the implemented changes. Further to this, non-specific codes such as F15.8 and F15.9 were removed from the proforma.

Data in cycle 1 was collected for attendances in September 2022 which included a new intake of trainees who may be unfamiliar with activity coding practices. This may have affected the data and resulted in greater coding inaccuracies in that month.

Turner et al. 2023 found in their regional multi-centre audit that none of the units were able to meet the 90% set standard, with the highest accuracy of 86% at one unit⁵. We found our own

OPCS

accuracy to be similar at 84% which would suggest a 90% standard to be an achievable target with further improvements.

F43.9

Inclusions Assessment Two or more orthodontic consultants present Assessment by multi-professional team Orthodontic consultant and different specialty Assessment by multidisciplinary team consultant present, MAS assessments Exam and no treatment – use at NPC Unspecified other examinations of mouth

F15.1 F42.4 F42.5

Creation of orthodontic impression Photography of mouth Recording of jaw relationships

F14.1 F14.2 F14.3

Treatment Insertion of fixed orthodontic appliance NEC Insertion of removable orthodontic appliance Insertion of orthodontic appliance NEC

F14.6 F15.2

Insertion of orthodontic anchorage Fitting of orthodontic bracket

F15.3 F15.4 F16.7 F15.5 F15.6 F16.8

Fitting of orthodontic headgear Fitting of orthodontic separator(s) Polishing of teeth Adjustment of orthodontic appliance NEC Repair of orthodontic appliance Other specified operations on tooth

F15.7

Debonding of orthodontic bracket

F14.4

Removal of orthodontic appliance NEC

F14.7

Removal of orthodontic anchorage

X62.2 X62.3

Description

END

DURING

START

Records

F65.1 F65.2 F65.3 F65.4 F65.5 F66.1 F66.2 F66.3 F66.4 F66.5 F67.1 F67.2 F67.3 F14.5 F40.5 F10.9 F16.4

Impression, digital scan Intra-oral and extra-oral photos Face bow/wafer try in (not wax bite) Bond-up of full arch/sectional fixed appliance URA, habit breaker, aligners (not functional) TPA/Nance/Quad Helix/RME (fixed habit breaker/space maintainer) Fit TAD (any number) Brackets/bands/tubes including repairs (for bond-up use F14.1)

Handpiece to polish or remove composite Adjust of FA/QH/RME/URA/aligners Any repair of fixed/removable appliance Interproximal/incisal reduction using hand-held strips or handpiece Removal/reposition of bracket/band/RME/QH/TPA/Nance Debond sectional/full arch including molar bands or tubes Remove TAD (any number)

Functional Any class II corrector or fixed functional device Fitting of fixed functional appliance Any removable functional appliance Fitting of removable functional appliance Tightening, activation of components Adjustment of removable functional appliance Adjustment of fixed functional appliance Removal of fixed functional appliance Retention Essix/VFR, Hawleys, Begg Fitting of removable orthodontic retainer Fitting of fixed orthodontic retainer Tightening, trimming, easing acrylic Adjustment of removable orthodontic retainer Repair of fixed retainer using composite Adjustment of fixed orthodontic retainer Any fixed retainer wire Removal of fixed orthodontic retainer Miscellaneous MAS - do not use if imps at NPC (use X62.3 only) Creation of impression for intraoral appliance MAS, cover plate, TMJ splint, speech plate Fitting of intraoral device Relating to F67.2 appliances Adjustment of intraoral appliance Open or closed Surgical exposure of tooth Removal of suture from mouth Primary or permanent teeth Unspecified simple extraction of teeth Handheld or ultrasonic Scaling of tooth

PLEASE INCLUDE CODES FOR ALL PROCEDURES YOU HAVE CARRIED OUT

Figure 3: Departmental orthodontic coding proforma

May 2025 Clinical Effectiveness Bulletin 23

Recommendations 1. Designate a clinician to be a coding advocate who can assist in educating and signposting the clinical team.

2. Identify a named contact/team from the coding department to support the clinical team and quality assurance processes.

3. Highlight the importance of accurate coding and the responsibility of the whole team to improve and maintain standards.

4. Resources and training should be provided to all existing and new staff members as coding practices can vary between trusts.

5. Coding proformas should be specifically designed for the workload and characteristics of each orthodontic department.

6. Explanations for procedure codes should be as clear as possible and ordered logically for ease of use.

7. Coding proformas should be readily available to clinicians and clearly visible in clinical Project involvement Henry Quach (Project lead, data collection, manuscript drafting) Sapna Radia (Project supervisor) Lucy Davenport-Jones (Project supervisor, manuscript approval) Acknowledgements The authors would like to thank Bozena Piggott and Mark Watson for their support with coding and financial queries.

References 1. NHS England. OPCS Classification of Interventions and Procedures. https://www.datadictionary.nhs. uk/supporting_information/opcs_classification_ of_interventions_and_procedures.html [Accessed 2024 June 1] 2. Jones E. Hospital Dentistry GIRFT Programme National Specialty Report. GIRFT. 2021.

3. British Orthodontic Society. Activity Coding in Orthodontics. Information for Secondary Care Trusts. https://www.bos.org.uk/wp-content/uploads/2023/06/Activity-Coding-inOrthodontics-2023.pdf [Accessed 2024 June 1]

24 Clinical Effectiveness Bulletin May 2025

4. NHS England. NHS Payment Scheme. https://www.england.nhs.uk/wp-content/ uploads/2023/03/23-25-NHS-PaymentScheme_v1.1.pdf [Accessed 2024 June 1] 5. Turner S, Harrison J, Hosni S. Orthodontic clinical coding: A two-cycle regional audit. BOS Clinical Effectiveness Bulletin 2023; 50: 17-19.

6. Shahid M, Tindall A. Payment by results: are we missing something? Int J Health Care Qual Assur 2013; 26: 387–391.

7. Naran S, Hudovsky A, Antscherl J, Howells S, Nouraei SA. Audit of accuracy of clinical coding in oral surgery. Br J Oral Maxillofac Surg. 2014 Oct;52(8):735-9.

8. Heywood NA, Gill MD, Charlwood N, Brindle R, Kirwan CC; Northwest Research Collaborative.

Improving accuracy of clinical coding in surgery: collaboration is key. J Surg Res. 2016 Aug;204(2):490-495.

A re-audit of the rate of unscheduled orthodontic appointments at Chesterfield Royal Hospital Zinab Kassir (DCT) and Jonathan Sandler (Consultant) Chesterfield Royal Hospital, Chesterfield Background/Rationale Emergency appointments in orthodontics are commonly caused by issues with fixed appliances and broken or lost retainers1,2. These problems often arise from poor patient compliance or clinical factors such as inadequate techniques or materials2.

Emergency appointments are costly to both clinicians and the NHS, as they require additional clinical time, resources, and laboratory expenses. There may be increased waiting times for new patients due to limited availability of appointments. Additionally, patients and caregivers will need to take more time off work or school for these extra visits2.

Frequent emergency appointments and delays in treatment can lengthen the total treatment time, potentially resulting in more patient or clinician-initiated discontinuation of treatment, or residual need after treatment. In 2019, NHS expenditure on primary care orthodontics reached approximately £250 million annually3. Data from northwest England revealed that treatment discontinuation and residual need resulted in an annual NHS expenditure of £3.9 million3.

Understanding the causes and patterns of emergency orthodontic appointments can inform clinical practice changes aimed at reducing their frequency and associated impacts. At Chesterfield Royal Hospital (CRH), the unscheduled appointment rates were reported at 5.96% in 2015 and 6% in 20111.

Aims and Objectives To identify the frequency, pattern and causes for emergency orthodontic appointments at Chesterfield Royal Hospital.

Audit type Retrospective audit.

Methodology The data was collected using a data collection form containing tick boxes to record the number of Standards/guidelines/evidence base previous unscheduled appointments, the specific The audit standard was established based on reason for attendance, and the type of orthodontic previous published audits conducted within the orthodontic department, stating that no more than appliance used. This information was subsequently 5% of total appointments should be unscheduled2. entered into Microsoft Excel for analysis. During the data collection period, a total of 8,937 patients This standard was formally approved by the attended the orthodontic department for department. follow-up appointments, excluding new patient visits. Out of these, 783 appointments were unSample and data source scheduled; however, only 247 data collection forms This audit was carried out within the orthodontic were completed. Therefore, our audit used data department at CRH. A data collection form should from these completed forms, representing 31.6% be completed by the treating clinician, for every of the total unscheduled appointments. patient that attended an unscheduled appointment. The data collection form had been designed following the previous audit cycle in Findings 2015.

The unscheduled appointment rate at CRH was Data was collected between the 2nd of April 2019 and the 10th of January 2023 using clinical codes.

During this time, 783 patients attended an unscheduled appointment and 247 data collection forms were completed. Data from the completed data collection forms was analysed retrospectively and used in this audit.

8.8%, which is 3.8% higher than the set standard.

May 2025 Clinical Effectiveness Bulletin 25

Figure 1: Reason for unscheduled appointment (type of appliance).

Figure 2: Reason for unscheduled appointment (detailed).

The majority of patients attended due to an issue with their fixed appliance (75%), shown in figure 1.

As seen in figure 2, the most common cause was due to a debonded bracket (35.2%) or due to the arch wire digging in (11.9%), followed by arch wire being out of tube/bracket (7.5%). Loose bands, fractured wires and lost power chains were also common reasons for attendance (4.8%). Removable retainer problems were the second most common cause of unscheduled appointments (8.9%). These were subdivided into lost appliances, fractured appliances, or the appliance not fitting. Lost and fractured appliances made up 7.2% of all unscheduled appointments (figure 2).

26 Clinical Effectiveness Bulletin May 2025

Figure 3: Number of previous unscheduled appointments attended.

Figure 3 shows the number of unscheduled appointments patients previously attended.

Notably, 30.4% of forms lacked this information.

Approximately a quarter of patients had never previously attended an unscheduled orthodontic appointment (23.5%), while 23.1% had attended only one. A smaller number of patients (15%) attended a couple of unscheduled appointments, and 8.1% had multiple appointments (three to twelve).

Observations The rate of unscheduled orthodontic appointments at Chesterfield Royal Hospital exceeded the target of 5%, which also reflected a 2.8% increase from 2015. The data collection period included times when the department was closed due to COVID-19, which later reopened for emergencies for a few months, before returning to usual clinical practice. The effect of COVID-19 on orthodontic care has been well documented and has been shown to affect patients' mental well-being⁴. This, along with long gaps in attendance may have affected the patient’s compliance with dietary issues and appliance care instructions, leading to more debonded brackets and fractured wires. Furthermore, the cancellation of scheduled review appointments during this unique period disrupted the routine maintenance of appliances.

Debonded brackets were the most common reason for unscheduled appointments, with a 7% increase since 2015. In the British Orthodontic Society (BOS) patient information leaflets⁵, it is written clearly that certain dietary habits can damage braces and lead to fractured wires.

Increasing patient education about appliance care at each appointment can reduce avoidable damage to fixed and removable appliances.

Additionally, when providing removable appliances, patients should be informed about the £40 replacement fee for lost or damaged appliances.

A small percentage of patients attended with pain or concerns that were managed with advice. This can be reduced by providing thorough instructions at the beginning of treatment and directing patients to the BOS website’s patients advice page.

This audit relied heavily on clinicians correctly

completing the forms. Only 31.55% of clinicians submitted a data collection form after an unscheduled appointment. Some forms had missing data, for example, 30.4% of forms analysed lacked information regarding previous unscheduled appointments attended. This was an improvement from the audit completed in 2015, where 58.6% of the forms were incomplete.

The original data collection form used tick boxes but had significant overlap in the reasons for attendance, which reduced the significance of each category and complicated data analysis. The design of the form also meant that details about the reason for attendance or the measures taken to correct this, were frequently missed off.

Recommendations 1. Given that a significant proportion of emergencies were due to debonded brackets, clinicians must ensure excellent moisture control and follow correct bonding techniques.

When complete moisture control is not achievable, the use of bands on posterior teeth should be considered. Modifying the data collection form to capture specific teeth details would help identify teeth that are at a higher risk of debonded brackets, potentially guiding the use of bands in those cases.

2. Dietary advice, oral hygiene instruction and specific appliance care instructions should be communicated clearly to the patient and adult carers. This information should be reinforced at each appointment, accompanied by written instructions. Each unscheduled visit presents an opportunity to assess compliance and re-educate the patient. Clinicians should also identify and counsel patients who have attended multiple unscheduled appointments.

Noting this in their files will help subsequent clinicians understand their attendance history during follow-up visits.

3. To enhance data collection, clinicians will be encouraged to complete forms accurately for every unscheduled appointment. Other dental team members, including dental nurses and receptionists, should encourage this practice.

The data collection form will be redesigned with more concise tick boxes, sections for treatment details, and specific tooth information. This aims to improve data quality and facilitate more accurate trend analysis.

May 2025 Clinical Effectiveness Bulletin 27

4. These recommendations will be shared with staff during clinical governance meetings and through email. The audit will be repeated in 18 months using the updated data collection form.

Project involvement Zinab Kassir Jonathan Sandler References 1. Dyke A, Sandler J. Audit of unscheduled orthodontic appointments at Chesterfield Royal Hospital. BOS Clinical Effectiveness Bulletin 2015; 35: 8–10.

2. Howell J, Muir J, Juggins K, et al. Unscheduled orthodontic attendances: A re-audit. BOS Clinical Effectiveness Bulletin 2015; 35: 31-33.

3. Price J, Whittaker W, Birch S, Brocklehurst P, Tickle M. Socioeconomic disparities in orthodontic treatment outcomes and expenditure on orthodontics in England’s state-funded National Health Service: a retrospective observational study. BMC oral health 2017; 17(1):123.

4. Alam MK, Abutayyem H, Kanwal B, Alswairki HJ. Effect of COVID-19 on orthodontic treatment/practice- A systematic review and meta-analysis. J Orthod Sci 2023; 12:26.

5. British Orthodontic Society. What happens if I keep damaging my brace? 2019. Available at https://bos.org.uk/wp-content/uploads/2022/03/ British-Orthodontic-Society-Food-and-DrinkMarch2019.pdf

28 Clinical Effectiveness Bulletin May 2025

Going the distance: Comparative analysis of a dramatic change in protocol for patient attendance at Cleft Lip & Palate MDT clinics Sean Daley (ST), Sasha Brannen (Post-CCST), Lucy Burbridge (Consultant Paediatric Dentist) and Rye Mattick (Consultant Orthodontist) Department of Orthodontics, School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK Background/Rationale Before 2019, the Northern site of the Northern and Yorkshire Cleft Lip and Palate Service operated several regional clinics in a hub and spoke structure1. The clinic typically assessed approximately 23 patients per session. Patients from infancy to 16 years old were required to attend at least seven MDT sessions. This schedule posed significant challenges, including missed school for children, considerable work absences and travel demands for their parents2.

The COVID-19 pandemic mandated transformation in this model. Public health guidelines necessitated a shift towards telemedicine and a more selective approach to in-person visits3. This adaptation was not merely a temporary response but catalysed a long-term re-evaluation of clinical practices in the region.

The MDT clinic was centralised in Newcastle, and a triage system was implemented to review patient cases systematically. This system established key milestones for MDT appointments, streamlining the process to determine when face-to-face consultations were essential. If a patient did not need an in-person MDT visit, the team could decide whether a specialist's appointment was necessary.

Depending on the outcome of this assessment, the patient could be directed to a single speciality clinic or a telemedicine clinic, or they might receive a letter explaining that an in-person visit was not needed unless specifically requested by the patient.

This post-pandemic model has been maintained due to its perceived success in restructuring care delivery, though its effectiveness has yet to be formally evaluated.

Aims and Objectives To retrospectively apply post-COVID protocols to appointments held in a cleft clinic from February 1 to April 30, 2019, and determine whether these appointments would be maintained under the 2020 protocol.

Assess the change in the number of appointments using post-COVID protocols and evaluate the implications of altered appointments on travel, costs, schooling, and parental work.

Sample and data source The Clinical Standards Advisory Group (CSAG) recommended centralising cleft services in the UK to enhance patient outcomes. However, no single, universally mandated operating procedure or clinic layout has been established for these services.

While the NHS has developed service specifications that outline core and developmental standards for specialised cleft care, regional variations exist.

There is no published guidance or established gold standard model for clinic operation within cleft services across the UK.

Standards/guidelines/evidence base For this study, data was acquired from the Northern Region Database and The Cleft Registry and Audit Network (CRANE). The following information was gathered for each patient: Clinic date, Name, Medical Record Number, Age, Date of birth, Postcode, LAHSAL code and which site they attended. This data was from February to April 2019, with 416 patient records from the cleft MDT clinic were reviewed.

Project type A service evaluation using retrospective analysis to compare past appointments during the specified period with post-COVID protocols.

Methodology The data analysis was conducted retrospectively, focusing on patient interactions from February 1 to April 30, 2019. Two clinicians well-versed in the pre- and post-COVID protocols used in the cleft clinic carried out this process. They assessed whether the appointments held during the specified period would still have remained under the novel, post-COVID protocols.

May 2025 Clinical Effectiveness Bulletin 29

Furthermore, we gained knowledge of the potential benefits of these protocols in reducing the indirect burdens on patients and their families, such as travel expenses, missed workdays and school days. Distance calculations were conducted using Excel/GoogleMaps software, employing the patient's and clinic's postcodes to determine the most direct car route.

Finally, the study offered a unique opportunity to reflect on the broader implications of these healthcare delivery changes, particularly regarding sustainability, patient and family well-being, and the potential for integrating centralised care in routine clinical practices.

Inclusion/Exclusion Criteria: Inclusion Criteria: This study included only patients with a cleft lip and/or palate who are 16 or under. These patients represent the typical demographic that the cleft clinic serves.

Exclusion Criteria: Patients who attend the clinic but do not have a cleft are excluded from the study. This group includes individuals presenting with cleft-like symptoms in functions such as speech, requiring a multidisciplinary team review. These cases, while relevant to the clinic's broader service provision, fall outside the usual cleft care timeline and thus are not representative of the core patient group the study aims to analyse.

Findings From February to April 2019, 416 patient records from the cleft clinic were reviewed. Of these, 215 records were deemed eligible and subsequently included in the data analysis, all of which pertained to patients with a cleft lip and/or palate. 48% of the patients excluded were patients over 16 years old, non-cleft VPI, and plastic surgery review patients (e.g., hemifacial microsomia, head shapes, tongue-tie, and ear deformities).

Data analysis revealed that, on average, 24% of these patients were not brought to the cleft clinic over the assessed three-month period. Of those who did attend in 2019 and were evaluated against the criteria established by the 2020 pathway, approximately 69% would have been redirected. This evaluation framework was 30 Clinical Effectiveness Bulletin May 2025

designed with a 12-month window, 6 months on either side of the selected clinical milestone, to accommodate any discrepancies due to administrative errors or attendance anomalies.

The travel expenses were calculated in accordance with the Healthcare Travel Costs Scheme (HTCS), which, at the time of writing, compensated patients at a rate of £0.15 per mile for travel to secondary care appointments. Before the implementation of the 2020 pathway, the data showed that the average return travel distance for patients was 31.92 miles (HTCS expense of £4.79), accommodating the logistics of attending multiple district clinics where clinical staff were present.

With the advent of the 2020 pathway and the consequent centralisation of clinics to Newcastle, the average return patient travel distance increased to 43 miles (HTCS expense of £6.45).

Applying the 2020 protocol to this patient group reveals that individuals who would no longer meet the criteria for attending the Cleft clinic could achieve a cumulative cost saving of £948.15 across three months. This equates to an estimated annual saving of around £3792.60 for patients.

Furthermore, the collective time lost from schooling or work due to these non-qualifying attendances amounted to 588 hours.

Implementing the 2020 pathway would yield significant time savings, averting an average of roughly 4 hours per patient from being spent on additional and often unnecessary clinic visits.

The COVID-19 pandemic underscored the crucial role that education plays in children's academic and social development. Essentially, the broader population encountered the kind of school interruptions typically experienced by patients with cleft lip and palate. Post-pandemic research has illuminated the consequences of a lack of schooling⁴, providing the team with a deeper understanding of how these interruptions could affect the lives of their patients.

Observations for patients, estimated at £3792.60 annually, Historically, the cleft clinic's model necessitated alongside saving approximately 588 hours that regular, numerous in-person appointments across could be used for schooling or work (Figure 2). multiple specialties, involving considerable travel and resource commitment. Patients averaged a travel distance of 31.92 miles, indicating a significant demand for their time and the healthcare system's resources.

The transition to a centralised system has brought about significant operational improvements.

Previously, clinics were often overbooked with 23 patients per session, which resulted in late working hours for staff. The new protocol reduces the number of patients to 12 per clinic, allowing for better preparedness and more thorough consultations. This setup has improved the work environment substantially, facilitating timely appointments and enhancing patient experiences by providing more privacy, a calmer atmosphere, and ensuring consultations are completed within an hour.

Adopting post-COVID protocols marked a paradigm shift towards reducing in-person visits, favouring virtual consultations and centralised services.

Retrospective analyses indicate that 69% of traditional appointments would be redistributed to other clinics, highlighting an overreliance on face-to-face interactions (Figure 1).

Figure 1: Charts Illustrating Patient Data Feb-April 2019 Despite the increased average travel distance to 43 miles due to centralisation, the overall decrease in required appointments suggests a more efficient use of patient time and healthcare resources. This reformation could lead to significant cost savings

Figure 2: Infographic of Patient Factors Data Feb-April 2019 A critical development has been establishing a dedicated alveolar bone graft (ABG) clinic at the central unit. This clinic addresses previous challenges, such as suboptimal radiographic quality and unnecessary exposure from multiple radiographs at spoke units. It ensures the presence of all relevant specialists and high-quality imaging, thus enhancing patient care efficiency and reducing unnecessary risks.

The current practice reflects an evolved cleft care pathway prioritising patient-centric approaches, considering broader impacts on patient and family welfare. The refined processes have facilitated additional clinical treatment sessions for CLP patients, allowing clinicians to provide more focused and personalised care. This shift meets immediate clinical needs and supports a broader, more resilient healthcare landscape capable of comprehensively adapting to and effectively addressing patient care demands. The integration of these new practices is advocated to continue, reinforcing a healthcare system responsive to the nuanced needs of its patients.

Recommendations 1. Evaluation of Patient-Reported Experience Measures (PREMs) and Patient-Reported Outcome Measures (PROMs) for staff and patients.

2. Examination of the ABG patient cohort to determine the effects of the newly implemented clinic and protocol on their healthcare journey.

May 2025 Clinical Effectiveness Bulletin 31

3. Investigate the attendance patterns of non-cleft Velopharyngeal Insufficiency (VPI) patients to evaluate the specificity and focus of their clinic visits.

4. Conducting a prospective study over three months to evaluate the suitability of appointments and the "Was Not Brought" (WNB) rate.

Project involvement Sean Daley Sasha Brannen Lucy Burbridge Rye Mattick Acknowledgements Hazel Sample, Data Coordinator, The Cleft Registry and Audit Network References 1. Dudding T, Martin S, Popat S. An introduction to the UK care pathway for children born with a cleft of the lip and/or palate.

Br Dent J. 2023;234(12):943–6.

2. Grewal SS, Ponduri S, Leary SD, Wren Y, Thompson JM, Ireland AJ, et al. Educational attainment of children born with unilateral cleft lip and palate in the United Kingdom. Cleft Palate Craniofac J. 2021;58(5):587–96.

3. Shahrul AI, Abd Rahman ANA. Telemedicine as an alternative way to provide multidisciplinary cleft care during the COVID-19 pandemic. Open Dent J. 2021;15(1).

4. Blundell R, Costa Dias M, Cribb J, Joyce R, Waters T, Wernham T, et al. Inequality and the COVID-19 Crisis in the United Kingdom. Annu Rev Econ.

2022;14:607–36.

32 Clinical Effectiveness Bulletin May 2025

Recycling orthodontic impression trays: A sustainable improvement

Kirsty Ailie Carney (Ailidh) (Specialty Registrar), Rachael Bissett (Advanced Dental Technician), Elinor Chalmers (Clinical Lecturer and Specialist in Orthodontics) and Catherine Tothill (Specialist in Orthodontics) Background/Rationale Sustainability is defined as meeting the needs of the present without compromising the ability of future generations to meet their own needs1. Sustainability encompasses three pillars: economic, social and environmental. As clinicians, we must consider the clinical and cost effectiveness of our decisions, as well as the environmental impact.

The United Nation’s COP26, highlighted the need for dentistry to engage in efforts to promote and coordinate sustainability across policy, service delivery, provision of care, research and education. The NHS has set a target of being Net Zero by 2040. Net Zero is a state where the emission of greenhouse gases (GHG) from human activities is balanced by withdrawal of GHGs from the atmosphere2.

Within Dundee Dental Hospital and Research School’s (DDH&RS) orthodontic department, intra oral scans are taken for study models, however alginate impressions are taken for fabrication of orthodontic appliances, retainers and teaching purposes. Single use impression trays were disposed of in clinical waste which had financial and environmental impacts and reduced the sustainability of our department.

A quality improvement project was conducted which introduced recycling of impression trays to improve the sustainability of the department.

Aims and Objectives DDH&RS has set a target of reaching Net Zero. In the orthodontic department, intra oral scans are taken to create study models, reducing the need for alginate impression material, plastic trays and plaster, minimising our carbon footprint. However, alginate impressions are still taken for other purposes.

This quality improvement project aimed to determine whether recycling impression trays within the department would result in a reduction in the carbon footprint and financial expenditure of the department.

Sample and data source To the authors knowledge, there is no standard or guideline specifically relating to recycling orthodontic impression trays. The legislation and NHS Scotland policy, procedures and best practice guidance regarding the storage, collection and disposal of waste is extensive. All Dental Service Waste is also subject to the regulatory requirements of the Special Waste Regulations3.

Confirmation was sought from Ortho-Care (UK) Ltd that their orthodontic impression trays were

fabricated from high impact polystyrene, a recyclable material. However, impression trays required disinfection prior to recycling.

A carbon footprint is the sum of GHG emissions attributable to a given process. As each gas has a different global warming potential the quantities are expressed in “carbon dioxide equivalents” (CO2e).

A review of the literature revealed that the carbon dioxide equivalent of recycling is 21kg CO2e/ tonne, in comparison to disposing of clinical waste involving high temperature incineration is 1074kg CO2e/tonne⁴.

Standards/guidelines/evidence base The number and size of orthodontic impression trays recycled were documented on a customised data form on Microsoft Excel. Data was collected over an eight-week period between July and September 2023.

Audit type Quality Improvement Project.

May 2025 Clinical Effectiveness Bulletin 33

Methodology As we did not access or use identifiable patient information, Caldicott approval was not required.

A quality improvement team was formed with representation at orthodontic laboratory technician, orthodontic specialist and dental core trainee level.

Confirmation was sought from Ortho-Care (UK) Ltd that orthodontic impression trays were fabricated from high impact polystyrene, a recyclable material. The manufacturer advised that trays require disinfection with Actichlor solution of 1000ppm for 10 minutes prior to recycling.

Recycling of trays were authorised by our recycling contractor and approved by the Dental Infection Control Nurse for DDH&RS. A Standard Operating Procedure (SOP) was produced detailing the process to safely recycle orthodontic impression trays (Figure 1: Impression tray recycling SOP). The SOP was presented, and feedback sought from key stakeholders at a local clinical governance meeting. Following this, the SOP was distributed by email and implemented within the department.

Using a customised data form in Microsoft Excel, the number and size of impression trays recycled over an eight-week period from July - September were documented. Impression trays received from other departments for production of orthodontic

appliances were excluded as these were not produced by Ortho-Care (UK) Ltd and had not be confirmed as recyclable. Prior to this eight-week period, no impression trays within the Orthodontic department were recycled.

The weight of the trays and high impact polystyrene recycled was calculated (Table 1: Total number and weight of trays recycled over eight-week period).

The carbon dioxide equivalent and the cost associated with disposing of this weight of high-impact polystyrene in dry mixed recycling and clinical waste was calculated and compared.

Table 1: Total number and weight of trays recycled over eight-week period.

Figure 1: Impression tray recycling SOP

Figure 1: Impression tray recycling SOP 34 Clinical Effectiveness Bulletin May 2025

Findings Following implementation of the SOP, 233 impression trays were recycled in an eight-week period. This was 2.8kg of high-impact polystyrene, which can be extrapolated to approximately 18.2kg/year. The CO2e of high impact polystyrene is 3.3 CO2e/kg⁵.

The CO2e of disposing high-impact polystyrene in recycling is less than its disposal in clinical waste, 0.38kg and 19.5kg respectively. The CO2e saved by recycling 18.2kg of high-impact polystyrene is equivalent to driving 86.5miles by car⁶.

The tonnage cost for dry mixed recycling is significantly cheaper than clinical waste, approximately £83.33 and £503.94 respectively, dependent on the contractor. The financial saving was minimal during this period. The author would like to highlight, that when making changes to reduce the carbon footprint of a service, there can be unintended negative financial and social implications, this has not been identified with this quality improvement project.

lower environmental impact, with no negative, unintended social impact. Departmental compliance with the new SOP was outstanding and implementation of this change also resulted in financial saving for the department.

The eight-week period between July and September 2023 that data collection took place may not be entirely representative as clinicians may have been on leave, with cancellation of clinics. There may be greater environmental and financial savings when accounting for clinics completed during term time.

We aim to introduce recycling of impression trays into other departments throughout the hospital, thus improving financial and environmental savings further.

Recommendations The introduction of recycling orthodontic impression trays can reduce environmental and financial impact on the department.

1. Where possible, opt for intra oral scans, rather than alginate impressions, to reduce the use of raw materials and generation of waste.

2. Present this project at the British Orthodontic Conference to increase awareness of recycling of impression trays.

3. Encourage other departments to adopt impression tray recycling and scanning where possible. Repeat the project in the orthodontic department and in other departments who implement the SOP in one year to assess economic and environmental benefits.

Figure 2: CO2e and financial reductions over one year Observations As a department, we aim to continue the move to digital technology, minimising our raw material use and waste generation. However, when alginate impressions are required, we aim to practice as sustainably as possible.

The introduction of recycling of impression trays within our department has streamlined our system to minimise wasteful activity and prioritised a

Project involvement Kirsty Ailie Carney (Ailidh) (Project lead) Rachael Bissett Elinor Chalmers Catherine Tothill Acknowledgements The authors wish to acknowledge the Orthodontic laboratory team at DDH&RS for their continuing help and support.

May 2025 Clinical Effectiveness Bulletin 35

References 1. United Nations. Sustainability https://www. un.org/en/academic-impact/sustainability (accessed 13/12/2023) 2. Duane B, Lee MB, White S, Stancliffe R, Steinbach I. An estimated carbon footprint of NHS primary dental care within England. How can dentistry be more environmentally sustainable? British Dental Journal. 2017 Oct 27;223(8):589-593. doi: 10.1038/sj.bdj.2017.839. PMID: 29074898.

3. National Health Service Scotland. Generic dental waste awareness. Edinburgh: NHS Scotland; 2007 [cited 2024 May 15].

Available from: chrome-extension:// efaidnbmnnnibpcajpcglclefindmkaj/https:// www.scottishdental.nhs.scot/wp-content/ uploads/2014/07/Generic_Dental_Waste_ Awareness_2007ver02.pdf 4. National Health Service. Environmental outcomes: carbon footprinting for healthcare.

Version 2. 2023.

5. Vink E, Davies S. Life Cycle Inventory and Impact Assessment Data for 2014 Ingeo™ Polylactide Production. Industrial Biotechnology. 2015; 11 (3): 167-180 6. OpenCO2.net. CO2 converter [Internet]. [cited 2024 May 15].

Available from: https://www.openco2.net/en/ co2-converter

36 Clinical Effectiveness Bulletin May 2025

Magnetic resonance imaging and orthodontics: An audit of clinician knowledge and experiences Divya Pathak (ST) and Fiona S Ryan (Consultant) Orthodontic Department, Eastman Dental Hospital, University College London Hospitals NHS Trust, London Background/Rationale Children and adolescents comprise the largest proportion of patients undergoing orthodontic treatment. Brain cancer is the second most common cause of childhood cancer in 0-14 years, accounting for nearly one-quarter of total cancers in this age group1 with 450 children diagnosed with a brain tumour each year in the UK. Over three-hundred thousand Magnetic Resonance Imaging (MRI) scans are carried out by NHS England annually, most commonly for investigation of Brain and Central Nervous System (CNS) cancers2. Radiology requests are often received for the removal of orthodontic appliances in patients undergoing MRI scans due to the risks of debonding, thermal effects and artefacts3 -⁷. There is limited guidance available to clinicians when orthodontic patients are required to undergo MRI scans, which can result in unnecessary removal of orthodontic appliances⁸.

Aims and Objectives The primary aim of this audit was to assess orthodontic clinicians’ knowledge of the principles of Magnetic Resonance Imaging and the risks/effects of orthodontic appliances on MRI scans. The secondary aim was to assess if this knowledge improved following a targeted teaching session.

Standards/guidelines/evidence base No prior research has evaluated the extent of orthodontists' knowledge of Magnetic Resonance Imaging (MRI), and thus no recognised gold standard exists. A previous study assessing orthodontists' knowledge of Cone-Beam Computed Tomography (CBCT) utilised the overall percentage of correct answers from a set of knowledge-based questions as a measure of knowledge level, defining 80% as high⁹. Consequently, a locally agreed standard was established, specifying that orthodontic clinicians should achieve an overall score of 80% on knowledge-based questions pertaining to MRI scans and orthodontics Sample and data source The Orthodontic Department at the Eastman Dental Hospital, London, has a total of 49 clinicians, including sixteen Consultants, thirty Registrars including post-CCSTs and three Specialists.

Potential participants were initially recruited from a departmental audit meeting attendance record and email mailing list for those not present.

Thirty clinicians in attendance at the departmental audit meeting on 8/4/24 were invited to complete two online novel surveys between 8/4/24 and 15/06/24.

In cycle one, twenty-eight questionnaire responses were received with a response rate of 93%. In cycle two, twenty-four responses were received in cycle two with a response rate of 80%.

Audit type Prospective, two-cycle knowledge-based audit.

Methodology Survey Design: Based on previous literature, two novel questionnaires were devised by the audit team with the aim of distribution prior to and following a targeted teaching session. The questionnaires consisted of a total of ten questions, six of which were a mixture of true/false and multiple-choice knowledge-based questions assessing clinicians’ knowledge of the principles of MRI scans and the effects of orthodontic appliances. Four questions assessed clinicians’ personal experiences of managing orthodontic patients undergoing MRI scans, including their responses to requests for removal of orthodontic appliances mid-treatment.

Both questionnaires were hosted on the online platform Survey Monkey, sent to clinicians via links on Microsoft Teams and followed-up by NHS email.

May 2025 Clinical Effectiveness Bulletin 37

Cycle one: Questionnaire 1 (baseline) was distributed to all orthodontic registrars, specialists and consultants at Eastman Dental Hospital at a departmental audit meeting on 8/4/24 with the aim of assessing their baseline knowledge prior to formal teaching.

Intervention:

Findings In cycle one, 28 questionnaire responses were received with a response rate of 93%. In cycle two, 26 responses were received with a response rate of 80%.

Experience-based questions were included in cycle one findings. Knowledge-based questions were included in the results of both cycles.

Following cycle one, a virtual, targeted, interactive teaching session on Microsoft Teams was delivered at a departmental audit meeting, outlining the principles of Magnetic Resonance Imaging and discussing the evidence-base pertaining to the risks and effects of orthodontic appliances on MRI scans and vice-versa.

Experiences of MRI scans in orthodontic patients

Cycle two:

Over a fifth (21%) had modified a fixed appliance before an MRI scan. Modifications included debonding of the fixed appliance, removal of archwires, placement of ceramic appliances and removal of accessory appliances e.g. ligatures and lacebacks.

A second questionnaire was distributed following the teaching session on 8/4/24 to the same clinicians that completed the baseline survey through an online link shared via Microsoft Teams.

Follow-up emails were subsequently sent on 1/5/24 and 11/6/24 reminding all clinicians to complete the survey.

Over a third of clinicians (39%) received a request to remove fixed appliances because a patient was having an MRI scan. Just over a third (36%) had treated or supervised a case where a patient was unable to have fixed appliances due to MRI scans.

35%

30% 25% 20% 15% 10% 5% 0%

Debonding of fixed appliance

Removal of archwire Placement of ceramic Removal of accessory appliance appliances e.g. ligatures

Figure 1: Modifications required to fixed appliances due to MRI scan requests in orthodontic patients

38 Clinical Effectiveness Bulletin May 2025

Knowledge of current guidelines

Knowledge of MRI scans and orthodontic appliances

selected Joules as units of strength of the magnetic field, reducing to 4% answering incorrectly in cycle two. In both cycles, 96% of clinicians correctly identified that MRI scanners utilise radiofrequency pulses and magnetic gradients to produce images. In cycle one, 82% correctly identified that hydrogen protons are used in MRI scans due to their abundance in the human body, further improving to 96% in cycle two.

Regarding the risks of MRI scans in patients with fixed appliances, 86% correctly recognised artefacts as a risk in cycle one which improved to 96% in cycle two. In cycle one, 46% correctly selected thermal trauma as a risk, improving to 79% in cycle two. Initially, only 32% correctly identified projectile debonding as a risk which improved to 83% in cycle two. In cycle one, 25% incorrectly thought radiation was a risk of MRI scans, reducing to 12% in cycle two. 11% incorrectly thought ocular injuries were a risk in cycle one compared to just 4% in cycle two.

46% of clinicians correctly identified that MRI scans do not impart radiation to patients. This improved to 83% in cycle two. 50% of clinicians incorrectly

In cycle one, 54% correctly identified that fixed appliances do not always need to be removed for MRI scans improving to 87% in cycle two.

Almost two-thirds (64%) were aware of MRI advice included in British Orthodontic Society guidelines ‘Orthodontics in patients with significant medical co-morbidities’10. .

Only 18% were aware of local trust guidelines. No clinicians were aware of Polish Orthodontic Society guidelines. One quarter of respondents (25%) were not aware of any guidelines regarding MRI scans and orthodontic treatment.

In cycle two, awareness of guidelines increased to 87% for British Orthodontic Society, 70% for Polish Orthodontic Society and 57% for local trust guidelines.

Question

Answer

% of correct responses in cycle 1

% of correct responses in cycle 2

MRI scans impart lower but not negligible radiation dose to patients

False

46%

83%

The strength of the magnetic field in an MRI scanner is typically measured in units of Joules

False

50%

96%

MRI scanners utilise radiofrequency pulses and magnetic gradients to produce detailed images of the body's internal structures

True

96%

96%

Hydrogen protons are the most commonly used nuclei for imaging in MRI due to their abundance in the human body, primarily in water and fat molecules

True

82%

96%

The risks of MRI scanning in patients with fixed orthodontic appliances include:

Thermal Trauma Artefacts Projectile Debonding

46% 86% 32%

79% 96% 83%

Fixed appliances must always be removed prior to MR imaging of the head and neck region

False

54%

87%

Figure clinician 2 – Orthodontic clinician responses to knowledge-basedquestions questions on on MRI MRI scans,scans, comparison Figure 2: Orthodontic responses to knowledge-based comparison of of cycle one and cycle two cycle one and cycle two

May 2025 Clinical Effectiveness Bulletin 39

Observations Baseline knowledge of Magnetic Resonance Imaging and Orthodontics was substandard in cycle one with an average total knowledge score of 61.5%. This was significantly short of our agreed standard that orthodontic clinicians should achieve an overall score of 80% on knowledge-based questions pertaining to MRI scans and orthodontics.

A simple and effective teaching session resulted in substantial improvement of clinicians’ knowledge between cycle one and two, increasing the overall knowledge score to 89.5%, a total improvement of 28%.

It was not possible to compare differences in knowledge between registrars, specialists and consultants as the surveys did not require the clinician answering to specify their grade as it was felt that this may lead to some individuals being identifiable due to the small numbers in some subgroups. This can be taken into consideration in future larger sample audit cycles, where these data may be beneficial to tailor further teaching to specific training grades.

A further limitation of this audit is that the second cycle questionnaire was administered immediately following the teaching session. This timing may not accurately reflect long-term knowledge retention as some degree of knowledge attrition typically occurs over time.

Finally, this single-centre audit captures the experiences and knowledge of a limited number of clinicians locally. To obtain a broader perspective of the understanding and experiences of the orthodontic workforce nationwide, further research is required.

Recommendations 1. Accounting for expected knowledge attrition over time, annual teaching should be provided to the orthodontic team. Teaching should cover the principles of Magnetic Resonance Imaging, the effects of orthodontic appliances on MRI scans and highlight existing guidelines available.

40 Clinical Effectiveness Bulletin May 2025

2. A re-audit of clinician knowledge and experiences of Magnetic Resonance Imaging and orthodontics should be carried out within 12 months.

3. There is limited guidance available to enable evidence-based decisions justifying removal or modification of appliances when orthodontic patients require MRI scans. Therefore, future research should aim to capture knowledge and experiences of the orthodontic workforce nationally.

Project involvement Divya Pathak (Project lead, design, data collection, writing of manuscript) Fiona S Ryan (Project supervisor, project design, review of manuscript.)

Acknowledgements Thank you to all the clinicians in the orthodontic department at Eastman Dental Hospital for their engagement with teaching and survey completion.

References 1. Feltbower RG, Fleming SJ, Picton SV, Alston RD, Morgan D, Achilles J, et al. UK case control study of brain tumours in children, teenagers and young adults: a pilot study. BMC Res Notes. 2014 Jan 8;7:14. doi: 10.1186/1756-0500-7-14.

2. NHS England Diagnostic Imaging Dataset 2022-2023. 18 May 2023. Available from: https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2023/05/Statistical-Release18th-May-2023-PDF-471KB-1.pdf 3. Poursattar Bejeh Mir A, Kamel M. Should the orthodontic brackets always be removed prior to magnetic resonance imaging (MRI)? J Oral Biol Craniofac Res. 2015;6:10. doi: 10.1016/j. jobcr.2015.08.007.

4. Reda R, et al. An update of the possible applications of magnetic resonance imaging (MRI) in dentistry: a literature review. J Imaging.

2021;7(5):75. doi: 10.3390/jimaging7050075.

5. Görgülü S, Ayyildiz S, Kamburoğlu K, Gökçe S, Ozen T. Effect of orthodontic brackets and different wires on radiofrequency heating and magnetic field interactions during 3-T MRI. Dento-maxillofac Radiol. 2014;43:20130356.

6. Hasegawa M, Miyata K, Abe Y, Ishigami T. Radiofrequency heating of metallic dental devices during 3.0 T MRI. Dentomaxillofac Radiol.

2013;42(5):20120234.

7. Beau A, Bossard D, Gebeile-Chauty S. Magnetic resonance imaging artefacts and fixed orthodontic attachments. Eur J Orthod.

2015;37(1):105-10. doi: 10.1093/ejo/cju020.

8. Shivam R, Rogers S, Drage N. An evidence-based protocol for the management of orthodontic patients undergoing MRI scans. Orthodontic Update. 2021;14:32-5. doi: 10.12968/ ortu.2021.14.1.32.

9. Hashim H, AlSharbati R, Bader L, Kasouma E, Hashim M, Al-Sayed N. Knowledge and attitude of orthodontists towards cone-beam computed tomography (CBCT). Eur J Med Health Sci. 2022;4:22-8. doi: 10.24018/ejmed.2022.4.6.1481.

10. Alawsi F, Sawbridge D, Fitzgerald R. Orthodontics in patients with significant medical co-morbidities. J Orthod. 2020;47(1_suppl):4-24. doi: 10.1177/1465312520949881. .

May 2025 Clinical Effectiveness Bulletin 41

Empowering people: Patient initiated follow up in orthodontics Nermin Hayek (ST), Eileen Watt (Consultant) and Fiona S Ryan (Consultant) Orthodontic Department, Eastman Dental Hospital, University College London Hospitals NHS Trust, London

Background/Rationale There has been a recent shift to putting patients at the heart of their healthcare journey and a wider appreciation that a one-size-fits all approach cannot meet the needs and expectations of the individuals we treat1.

The NHS Long Term Plan has outlined that personalised care is a commitment of NHS England, where patients should be able to have control and choice over their care pathways to accommodate their values, needs and preferences2,3.

Patient Initiated Follow Up (PIFU), forms an integral part of personalised care - allowing a patient, or carer, to initiate follow-up appointments when they need one. It empowers patients to engage in shared decision making and enables clinicians to offer a more flexible patient pathway.

Within orthodontics, this may be useful for patients in retention who require longer term follow up - the current departmental criteria for PIFU is post debond hypodontia patients awaiting restorative treatment. This cohort of patients would have been routinely reviewed every 3 months for a year post-debond - PIFU therefore has scope to offer a safe and effective solution to avoid routine follow-up appointments and streamlining patient care.

Aims and Objectives The main aim of this two-cycle audit was to assess compliance of care for orthodontic patients placed on the PIFU pathway in accordance with the departmental standard operating protocol (SOP) in the University College London Hospitals (UCLH) Trust. The secondary aim was to assess the outcome of any PIFU episode (i.e. have patients triggered a follow-up appointment and were the appointments SOP-compliant).

Standards/guidelines/evidence base The standard was set so that 100% of orthodontic PIFU patients should be sent a PIFU clinic letter to ensure a safe introduction of this new service. The compliance with all elements of the SOP were also assessed, these included: Correct Patient: • Patient on the PIFU pathway for correct clinical reason: According to the SOP, any hypodontia patient that had been debonded more than 1 year ago and was currently awaiting restorative treatment was eligible to be placed on a PIFU pathway.

Documented Discussion •

Documented discussion with the patient regarding PIFU in the medical notes.

42 Clinical Effectiveness Bulletin May 2025

Correspondence: • Correct correspondence to GDP and patient regarding PIFU sent: a PIFU specific clinic letter to be sent to the patient and their general dentist, detailing the specific orthodontic triggers that warrant initiation of an appointment.

Outcome: •

Any self-triggered appointments booked within 5 working days and be compliant with the patient’s specific triggers. The target for this was reduced to 80%, as there may be exceptional circumstances that this cannot be met; for example, patients declining an earlier appointment due to other commitments.

Sample and data source The audit cohort comprised of all orthodontic patients placed on the PIFU pathway via the Electronic Patient Record (EPR) Database between its initiation in January 2022 and April 2023 for the 1st cycle and between May and October 2023 for the 2nd cycle. Exclusion criteria included patients who were booked onto the PIFU pathway in error, duplicate referrals and those intended for a different dental department. Forty-four and 28 patients were included in the first and second cycles, respectively.

Audit type A records-based audit was undertaken over two cycles.

Cycle one: Retrospective Cycle two: Prospective Methodology Approval for the audit was granted by the Trust Clinical Governance Committee. Following this, a data capture spreadsheet was developed based on all aspects of the SOP for the management of patients on the PIFU pathway. Patient electronic records were screened and the data collection for the first cycle was undertaken from January 2022 - April 2023 with findings presented at the local Trust departmental audit meeting.

All attendees at the meeting were informed of the shortcomings identified and the recommendations to overcome them.

A simplified step-by-step flowchart on how to correctly place a patient on the PIFU pathway was formulated. Local teaching to all clinicians in the orthodontic department was delivered. A PIFU discussion smart phrase was devised and uploaded onto the electronic patient database for all clinicians to use.

Data collection for the second audit cycle was undertaken between May and October 2023.

Correspondence: It was deemed essential to construct a clinic letter to the patient and their general dentist detailing that they were on the PIFU pathway, what was considered as their “orthodontic triggers” to initiate an appointment and how to trigger a follow up appointment when needed. Eighty percent (n=28) of patients were sent a PIFU specific clinic letter with their personalised triggers. Twenty-six percent (n=9) of general dentists were sent a PIFU clinic letter.

Outcome Of the 35 orthodontic PIFU patients, 4 self-requested a follow-up appointment.

Seventy five percent (n=3) were seen within 5 working days and 25% (n=1) was seen at 9 days following their trigger. The reason for the delay was not documented. Of these patients, 100% complied with their orthodontic triggers (lost/ broken/ ill-fitting retainer or restorative work recently carried out).

Cycle two This was conducted following a departmental-wide re-training session on PIFU. Twenty-eight patients were identified during the audited timeframe, 100% of whom were included in the audit, showing an improvement in the clinician’s awareness of the appropriate use of PIFU.

Findings Cycle one

Correct Patient:

Correct Patient:

All the patients were in the retention phase of their treatment.

Forty-four PIFU patients were identified, 7 of whom were intended for a different specialty, 1 was a duplicate order and 1 was incorrectly placed onto the PIFU pathway. 35 patients fulfilled the inclusion criteria for the audit.

Documented Discussion: Eleven percent of records complied with the SOP where clear documentation of the clinician-patient discussion was observed.

Documented Discussion: Seventy five percent of records complied with the SOP criteria on clinician-patient discussion - a considerable improvement (of 64%) from cycle one.

Correspondence: Ninety three percent (n= 26) of patients were sent their PIFU clinic letter, a notable improvement from cycle one. A slight improvement was recorded when observing whether letters were May 2025 Clinical Effectiveness Bulletin 43

sent to the patient’s general dentist (39%), this still falls considerably short of the intended target, leaving scope for further improvement.

Outcome: One patient in cycle two self-requested a follow-up appointment due to a broken retainer. Each aspect of the SOP was met, showing 100% compliance.

appointment delay plays an important role in the overall results analysis and is now a compulsory task that has been relayed to the wider team.

All remaining standards of patient triggered appointments were met - all patients were seen at the right time and for the appropriate reasons. This highlights the large scope that PIFU has to offer in providing patients the flexibility of choice around their busy lifestyles.

Observations Between cycle one, which marked the start of PIFU use, and cycle two, compliance with all aspects of the SOP improved. The greatest improvement observed was in the PIFU documentation - a 64% increase (Figure 1). We hypothesise that this was due to the prepopulated smart phrase.

Results Table : Cycle One Vs Cycle Two 120%

100%

80%

Figure 2: The overall outcome of patients on the PIFU pathway, Cycle One compared with Cycle Two

60%

There has been an increase in the uptake of PIFU within the department since its initial implementation, supporting that its place within Orthodontics is justified (Figure 3).

40%

20%

0%

Correct Patient

Documented Discussion

Correspondence- Correspondence- Outcome- Seen OutcomePatient Dentist within 5 working Compliant with days Orthodontic Triggers Cycle One

Cycle Two

Figure 1: PIFU discussion documentation results In both cycles, the PIFU pathway was accurately utilised by patients (Figure 2). Although this constituted a small number of patients (n=4 in cycle one, n=1 in cycle two), it is encouraging to observe patient engagement in this new service.

When analysing the outcome of each appointment, one fell short of the target of being seen within 5 working days since the triggering an appointment.

Since the reason for delay was not documented, it was difficult to ascertain whether the patient had been offered an earlier appointment that was not deemed suitable, or whether there was a lack of clinic slot availability within the specified time frame. Documentation of the reason for 44 Clinical Effectiveness Bulletin May 2025

Figure 3: Monthly PIFU orders made in the Orthodontic department at UCLH, from implementation to the end of the audit timeframe The use of PIFU in our department has currently been limited to patients who have completed active orthodontic treatment and are in the retention phase, awaiting restorative treatment.

This sample was chosen to identify challenges with its implementation before a wider roll out.

It is anticipated that PIFU could also be applied to other patients in the retention phase, with some restrictions. However, due to the fact that orthodontic treatment is usually a defined condition with a finite treatment duration, as opposed to a chronic condition where review intervals can legitimately be patient-led, PIFU is likely to remain restricted to a subsection of the orthodontic patient base.

Recommendations 1. Regular reinforcements to clinicians on the local PIFU SOP during audit meetings 2. Dissemination of findings to a wider audience 3. Expansion of departmental criteria of patient placement onto the PIFU pathway 4. Re-audit after one year Project Involvement Nermin Hayek Eileen Watt Fiona S Ryan References 1. NHS England. NHS Long Term Plan [Internet].

2019 [cited 2023 Nov 9].

Available from: https://www.longtermplan.nhs. uk/wp-content/uploads/2019/08/nhs-long-termplan-version-1.2.pdf 2. NHS England. Personalised Care Model by 2024 [Internet]. [cited 2023 Nov 9].

Available from: https://www.england.nhs.uk/ wp-content/uploads/2021/03/B0423 -personalised-care-and-support-planningguidance-for-lms.pdf 3. Department of Health and Social Care.

Personalised health and care 2020: A framework for action [Internet]. 2014 [cited 2023 Nov 9].

Available from: https://www.gov.uk/government/ publications/personalised-health-and-care-2020/ using-data-and-technology-to-transformoutcomes-for-patients-and-citizens

May 2025 Clinical Effectiveness Bulletin 45

A two-cycle audit of periodontal assessment and appropriate management within the orthodontic department at a UK teaching hospital Kirandeep Nandhra (ST), Huw Jeremiah (Consultant) and Natasha Wright (Consultant) Orthodontic Department, Addenbrooke’s Hospital, Cambridge Background/Rationale The British Society of Periodontology (BSP) states that the Basic Periodontal Examination (BPE) is a minimum standard of care for initial periodontal assessment, and a BPE should be undertaken for all new patients aged 7+ years1. For children and adolescents under 18 years old, a simplified BPE (sBPE) is used as per the BSP and British Society of Paediatric Dentistry (BSPD) guidance in 20212 . The sBPE involves recording the BPE around all first permanent molars, the UR1 and LL1 only.

In addition, for 7-11 year olds, only BPE codes 0-2 are used. This is because the erupting first permanent molar and exfoliating second primary molar in this age group may result in the gingival margin being situated coronal to the cemento-enamel junction, giving the false appearance of a periodontal pocket.

There is a well-established correlation between gingival inflammation and orthodontic appliances, therefore all potential orthodontic patients should display oral hygiene to an exemplary standard with no active disease prior to accepting for treatment3. It is therefore critical to diagnose and manage pre-existing periodontal conditions prior to commencing orthodontic treatment, and recording a BPE and oral hygiene status are quick and effective screening tools to aid this.

Aims and Objectives The primary aims of this audit were to ensure all clinicians are recording oral hygiene status and basic periodontal assessment (BPE) at new patient assessments. The secondary aim was to ensure clinicians are taking subsequent appropriate action based on guidance from the BSP; This was defined in our study as delivery of oral hygiene instruction for BPE codes 1+ and advising patients to visit their general dental practitioner/ hygienist/ periodontologist for the recommended follow up care as appropriate.

Standards/guidelines/evidence base The BSP guidance document: Basic Periodontal Examination (2019)1 and ‘Guidelines for Periodontal Screening and Management of Children and Adolescents Under 18 years of Age’ (2021)2 formed the basis of this audit’s standards.

They advise that all new patients aged 7+ years should have a BPE recorded at their initial examination with specific guidance on recommended follow up actions for each code (Figure 1: BSP Summary guidance on interpretation of the Simplified BPE Codes). Based on this, our criteria for ‘appropriate management’ by the orthodontist was defined by the audit team as follows: Delivery of oral hygiene instructions for BPE codes 1+ and advising patients of the

46 Clinical Effectiveness Bulletin May 2025

Figure 1: BSP Summary guidance on interpretation of the Simplified BPE Codes recommended action to be completed by the general dental practitioner/ hygienist/ periodontologist as appropriate.

The standard was set as 100% for the record of BPE, oral hygiene status, and appropriate management by the orthodontist based on BSP guidance for each BPE code.

Sample and data source All patients who attended for a new patient assessment to a secondary care orthodontic department at a single UK hospital were included in the audit, with the following exclusion criteria: Patients < 7 years old, medical/ behavioural difficulties which significantly affected cooperation (and this was recorded in the notes), new patient referrals to the Cleft service.

The data was collected over 2 time periods, which were 6 months in duration. Data from cycle (1 March 2022 to August 2022) included a total of 177 patients, and data from cycle 2 (September 2023 to February 2024) included a total of 221 patients.

Data collection was carried out by a single clinician reviewing the records from all new patient clinics over the study period, by manually searching specific clinic codes in ‘Epic’ software; the electronic software used for all patient records within the department. Data was collected retrospectively for both cycles.

Audit type A retrospective two-cycle audit conducted within a secondary care orthodontic department.

Methodology A data collection tool was designed on Microsoft Excel, which included the following outcome measures: 1) Record of BPE (yes/no), 2) Record of oral hygiene status (yes/no), 3) Highest BPE code recorded, 4) Whether appropriate action was taken based on BSP guidance (yes/no), 5) What action was taken (if any).

Findings The first cycle (March 2022-August 2022) included 177 patients. Compliance in recording a BPE and oral hygiene status was 71% (n=125) and 96% (n=170) respectively, and 41% (n=72) had subsequent appropriate action taken. Of the BPE’s recorded, 11.2% had 0 as their highest BPE code, 28.8% had code 1, 50.4% had code 2, 8% had code 3 and 1.6% had code 4. Based on the gold standard of 100%, there was a failure to meet the set standard for all 3 outcome measures.

The second cycle (September 2023- February 2024) had a total of 221 patients. Compliance in recording a BPE and oral hygiene status both improved to 97% (n=215), and subsequent appropriate action improved to 73% (n=161). Of the BPE’s recorded, 18.6% had 0 as their highest BPE code, 35.3% had code 1, 42.3% had code 2, 3.3% had code 3 and 0.5% had code 4. When there was appropriate action taken, 54% had used the newly created proforma. Despite an improvement in all outcome measures, there was still a failure to meet the 100% gold standard for each parameter.

Observations Unfortunately, suboptimal oral hygiene and gingival condition was common among patients referred to the orthodontic department and in both cycles, BPE code 2 was the most frequently recorded value (Figure 2: Highest BPE recorded for cycle 1 and 2). This finding reinforces the importance of screening all patients and subsequently determining appropriate management.

Cycle 1 Vs Cycle 2: Highest BPE Code Recorded 1

After collection of cycle 1 data (March 2022-August 2022), the following action plan was implemented: Dissemination of results to the team and delivery of education slides as per the BSP guidance, templates for the digital clinical records were implemented to include checks for oral hygiene and BPE status, and a ‘smart tool’ on Epic software was created which prompts on appropriate action to be taken based on BPE codes. A 2nd cycle of data collection with the same parameters was then completed September 2023-February 2024.

0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0

0

1

2 Cycle 1

3

4

Cycle 2

Figure 2: Bar graph of results comparing cycle 1 and cycle 2 for highest BPE recorded

May 2025 Clinical Effectiveness Bulletin 47

The most common BPE code associated with a lack of ‘appropriate action taken’ was code 1, which the BSP guidance advises oral hygiene instruction delivery for. It was concluded during the dissemination of results to clinicians that this was often due to a lack of recording oral hygiene instruction delivery in the notes, despite it being done. An improvement in record keeping was therefore recommended after cycle 1.

Cycle 1 Vs Cycle 2 Results 1

When this audit was compared to previous similar studies, there was significantly better initial compliance at recording BPE for new patients (71% Vs 6.3% and 23%)⁴,⁵. However following implementation of change, all studies showed similar levels of compliance (97% Vs 94% and 95.1%)⁴,⁵.

Amin et al (2024)⁵ also looked at whether clinicians were taking appropriate action based on their BPE assessment. Their results showed lower levels of compliance after implementing change (43%) in comparison to our study (73%). However, the criteria for appropriate management differed, and theirs was defined as the referral of patients presenting with BPE codes 3 or 4.

Overall, this two-cycle audit demonstrated improvement in compliance to a high standard for all outcome measures, however the audit standard of 100% was still not met (Figure 3: Results for cycle 1 Vs cycle 2). The authors believe the reason for this is largely due to clinical time pressures and some clinicians having not incorporated the ‘smart tool’ proforma into their new patient assessment templates, which was often associated with a lack of delivery or documentation of appropriate action.

48 Clinical Effectiveness Bulletin May 2025

0.96

0.97

0.8 0.7 0.6

0.73

0.71

0.5 0.4

0.41

0.3 0.2 0.1 0

Additionally, in instances where patients were being discharged after their initial assessment, there was a reduction in compliance for appropriate action being taken. Clinicians were therefore reminded of their duty to inform patients of diagnostic findings and recommend appropriate follow up care even if they are not receiving orthodontic treatment.

0.97

0.9

BPE recorded

Oral hygiene status recorded Cycle 1

Appropriate action taken

Cycle 2

Figure 3: Bar graph of results showing an improvement in standard for record of BPE and oral hygiene status and appropriate action taken between cycle 1 and cycle 2 Recommendations As the gold standard of 100% has not been met in cycle 2 for all outcome measures, the following action plan has been agreed: 1. Disseminate cycle 2 results to the team.

2. Re-educate all clinicians on BSP guidance regarding periodontal screening and recommended subsequent management.

Appropriate further training will be recommended if deemed necessary.

3. Re-educate all clinicians on the importance of documenting oral hygiene status, BPE codes and subsequent action taken.

4. Ensure every clinician is aware of how to incorporate oral hygiene status, BPE code and the smart tool for appropriate action into their initial assessment templates.

5. Complete a 3rd cycle audit July-December 2024 to ensure the standard has been improved and the gold standard met.

Project involvement Kirandeep Nandhra (Audit design, data collection, education, presentation of findings) Huw Jeremiah (Assistance in audit design and project supervision) Natasha Wright (Assistance in audit design and project supervision)

References 1. British Society of Periodontology. Basic Periodontal Examination (BPE) guidelines [Internet]. BSP; 2019 [cited 2024 March 1].

Available from https://www.bsperio.org.uk/assets/ downloads/BSP_BPE_Guidelines_2019.pdf 2. British Society of Periodontology. Guidance For Periodontal Screening and Management of Children and Adolescents Under 18 Years of Age [Internet]. BSP; 2021 [cited 2024 March 1].

Available from https://www.bsperio.org.uk/assets/ downloads/Updated_BSP_BSPD_Perio_ Guidelines_for_the_Under_18s_2021_ FINAL_270921_vc_PDF_version.pdf 3. Kloehn JS, Pfeifer JS. The effect of orthodontic treatment on the periodontium. Angle Orthod.

1974 Apr;44(2): p.127-34 4. Quach H, Quach S, Ray-Chauduri A. Basic Periodontal Examination (BPE) in new orthodontic patients: a 2-cycle audit. Clinical Effectiveness Bulletin. BOS. September 2020. No. 45, pp. 6-8 [cited 2024 Nov 19].

Available from https://bos.org.uk/wp-content/ uploads/2022/04/British-OrthodonticSociety-CEB-45-DOC-Final-26-10-20.pdf 5. Amin N, Schwabe S, Elton V. Periodontal assessment prior to starting orthodontic treatment- A four- cycle audit. Clinical Effectiveness Bulletin. BOS. April 2024. No.52, pp.

52-55 [cited 2024 Nov 19].

Available from https://bos.org.uk/wp-content/ uploads/2024/04/CEB-52-Website-05-04-2024.pdf

May 2025 Clinical Effectiveness Bulletin 49

‘Making Every Contact Count in Orthodontics’: A regional quality improvement project Nabeela Caratela (DCT), Shane Higgins (Consultant Orthodontist) and Sheena Kotecha (Consultant Orthodontist) Birmingham Dental Hospital Background/Rationale ‘Making Every Contact Count’ (‘MECC’) is a national initiative encouraging health and social care staff to utilise opportunities during routine interactions with patients to discuss making improvements to their overall health and wellbeing. The goal of ‘MECC’ is to deliver succinct and consistent messages regarding health and wellbeing, encouraging patients to reflect on their modifiable risk factors. ‘MECC’ interactions should take seconds to a few minutes without adding to existing time constraints1.

Orthodontic clinicians and nurses see patients for regular and frequent review appointments compared to other dental professionals, building a rapport with patients over time. The team sees young patients during key transitional phases in their life such as moving schools and going to university. Evidence shows that readiness to change is more likely at these points in life2. Furthermore, unhealthy habits are more likely to develop as individuals begin to make their own lifestyle choices, independent of parental influence. Routine interactions with patients can be utilised to support patients towards improving their oral and general health.

Aims and Objectives To assess current levels of knowledge and awareness of the ‘MECC’ initiative amongst the orthodontic department.

To evaluate if the orthodontic department considerproviding patients with advice on behavioural risk factors and improving overall wellbeing as part of their job role.

To explore barriers to giving patients advice, gaps in knowledge, and perceptions of the ‘MECC’ initiative amongst the orthodontic department.

Standards/guidelines/evidence base The ‘MECC’ initiative is supported by evidence for behaviour change interventions in the National Institute for Health and Care Excellence (NICE) guidance. The guidance outlines how behaviour change interventions can be integrated in routine clinical practice3. There are different levels of interventions to facilitate behaviour change.

Provision of ‘very brief advice’ and ‘brief advice’ are recommended for ‘MECC’ activity1. The Delivering Better Oral Health (DBOH) toolkit also contains evidence-based guidance on how dental teams can support patients for a multitude of risk factors2.

This was a quality improvement project with no published standards.

50 Clinical Effectiveness Bulletin May 2025

Sample and data source All Orthodontic Consultants across the West Midlands Region were invited to participate in the project. The sites across the region included Birmingham Dental Hospital, Walsall Manor Hospital, Worcestershire Acute Hospitals, Shrewsbury and Telford Hospitals, New Cross Hospital, University Hospitals of North Midlands (Royal Stoke Hospital and County Hospital Stafford), Good Hope Hospital and Warwick Hospital. Orthodontic Specialty Registrars, Orthodontic Specialty Dentists, Orthodontic Therapists, and Orthodontic Nurses from the Birmingham Dental Hospital were also invited to participate in this project. There were no exclusion criteria.

In the first cycle, 52 responses were received, and 33 in the second cycle.

Audit type Prospective 2-cycle.

Methodology The quality improvement project was undertaken across the West Midlands Region through the distribution of a bespoke prospective questionnaire. The questionnaire was piloted with 3 clinicians, and agreed upon with the department lead, consisting of 10 questions to assess

knowledge, attitudes, current implementation and barriers surrounding ‘MECC’ amongst the Orthodontic Team (Figure 1).

The questionnaire was disseminated at the West Midlands Consultant Orthodontic Group Meeting via paper forms and for those not in attendance, via Google Forms in February 2024 (1st QIP cycle).

Following presentation of findings and the delivery of a face-to-face training session on ‘MECC’, a questionnaire to evaluate the impact of the

interventions was distributed via paper forms at the West Midlands Consultant Orthodontic Group Meeting and Departmental Dental Nurses Meeting in July 2024 (2nd QIP cycle). The training session was attended by Orthodontic Consultants, Specialty Registrars, Orthodontic Therapists and Dental Nurses. There were fewer attendees in the July meeting, accounting for the reduced number of participants. Furthermore, as the training session was delivered in-person only, online questionnaires were not distributed for those not in attendance.

Figure 1: Questionnaire posed to the Orthodontic Team in Cycle 1

May 2025 Clinical Effectiveness Bulletin 51

Findings First Cycle Data were collected from 52 respondents. The majority were Orthodontic Consultants (42%), followed by Orthodontic Nurses (27%) and Orthodontic Specialty Registrars (19%).

most frequently reported services to which the orthodontic team refers patients. Figure 3 highlights the resources and services signposted to by the orthodontic department.

The most common areas of advice given by the Orthodontic Team were tobacco and smoking cessation, diet advice and vaping/e-cigarette advice (Figure 2).

Figure 3: Responses for resources and services currently signposted to.

Figure 2: Areas of advice currently given by the Orthodontic Team.

Although 53% of respondents were aware of the ‘MECC’ initiative, only 6% of respondents had previously received training on ‘MECC’. In all cases, the training was delivered online. Seventy-nine percent of respondents felt that the orthodontic department should be giving advice that promotes general health as well as oral health, and a further 17% were unsure.

The five most common areas that respondents felt they had sufficient knowledge in were dietary advice (83%), smoking cessation advice (77%), alcohol reduction advice (39%), obesity advice (29%) and vaping/e-cigarette advice (29%). Mental health advice (23%), stress reduction advice (15%) and recreational drug advice (14%) were the areas where fewest respondents had sufficient knowledge in. Furthermore, 4% of respondents felt they had insufficient knowledge in all the listed subject areas.

Fifty-four percent of respondents were aware of services and resources for signposting patients.

Among these, smoking cessation services and referrals to general medical practitioners were the 52 Clinical Effectiveness Bulletin May 2025

Overall, 60% of respondents requested further training on ‘MECC’ but 23% were unsure if this was required. Of those who wanted further training, 61% requested face-to-face training, whilst 39% requested online training.

The main barriers to providing patients with advice regarding lifestyle factors were lack of time (90%), feeling uncomfortable about having sensitive conversations (52%) and lack of knowledge (50%).

A further 30% of participants felt they lacked confidence in providing advice, and 30% also felt patient non-compliance was a barrier.

Additional comments of note: ‘Sometimes patients are uncomfortable to disclose medical information as they feel it does not support their treatment.’

‘There are too many time pressures to feel like you can spend enough time to give advice, maybe signposting is more feasible.’

Second Cycle Data were collected from 33 respondents. The majority were Orthodontic Consultants (36%), followed by Orthodontic Nurses (30%) and Orthodontic Specialty Registrars (27%).

Following the presentation of findings, delivery of formal education and dissemination of resources to the orthodontic department, 85% of respondents reported an improved awareness and understanding of the ‘MECC’ initiative. Additionally, 91% indicated an improved awareness of resources available to signpost patients to, and 79% stated they were more likely to signpost and provide advice to patients as a result of the intervention.

Furthermore, 91% felt that the orthodontic team should promote both general and oral health.

Observations Initial results showed limited knowledge and training on ‘MECC’. The responses also highlighted a limited awareness of resources and services to signpost patients to. The tailored training session addressed this, highlighting key resources to broaden knowledge on signposting.

In the wider context of healthcare professionals, existing research mirrors a limited awareness of ‘MECC’ and the need to increase opportunistic behaviour change interventions during routine consultations⁴.

Lack of time was the most reported barrier to giving patients advice; however, this could have been a misconception due to lack of awareness regarding ‘MECC’ conversations. The recommended time taken to deliver ‘very brief interventions’ is 30 seconds to a few minutes, and this can be part of existing conversations that take place during history-taking1. Such interactions are designed to complement the provision of holistic care to patients and should not add to existing burdens.

Existing studies have also highlighted a perceived lack of time as a barrier to delivering behaviour change interventions⁴. Although clinicians reported an additional barrier was feeling uncomfortable with sensitive conversations, the evidence suggests patients are willing to receive advice from dentists on sensitive lifestyle topics, including obesity advice⁵.

Overall, knowledge and awareness of the ‘MECC’ initiative amongst the Orthodontic team improved following delivery of the training. Participants stated they were more likely to signpost and give advice to patients, and knowledge of local and national resources improved following the delivery of formal teaching. It is important to highlight that

the results of the second cycle should be interpreted with caution due to the reduced sample size. To ensure a more homogenous sample size between cycles in future, the in-person training session and questionnaire dissemination could be arranged virtually for those unable to attend.

Recommendations 1. A QR code with key resources will be disseminated to Orthodontic teams across the West Midlands to facilitate ‘MECC’ interactions and signposting.

2. The project was shared via a poster presentation at the British Orthodontic Conference in October 2024.

3. A peer-reviewed continuing professional development (CPD) guide for dental nurses was published in the Dental Nursing Journal in September 2024 to encourage wider team involvement.

4. Incorporation of ‘MECC’ information and resources in the departmental induction and handbook.

5. Completion of a further cycle of the project to measure the effect of the QR code and CPD resources.

Project involvement Nabeela Caratela (Project lead, data collection and analysis, presentation of results, manuscript drafting) Shane Higgins (Project Supervisor) Sheena Kotecha (Project Supervisor) Acknowledgements Thank you to Ms. Sheena Kotecha and Mr. Shane Higgins for supervising this project, and the West Midlands Consultant Orthodontic Group and the Orthodontic Department at Birmingham Dental Hospital for their support with this project.

References 1. Public Health England (2016). Making every contact count (MECC): Consensus statement.

Available at: https://www.england.nhs.uk/ wp-content/uploads/2016/04/making-everycontact-count.pdf (Accessed: 01 August 2024).

May 2025 Clinical Effectiveness Bulletin 53

2. Department of Health and Social Care (2021).

Delivering Better Oral Health: An evidence-based toolkit for prevention.

Available at: https://www.gov.uk/government/ publications/delivering-better-oral-health-anevidence-based-toolkit-for-prevention (Accessed: 01 August 2024).

3. National Institute for Health are Care Excellence (2024). NICE guidance. Available at: https://www. nice.org.uk/guidance (Accessed: 01 August 2024).

4. Keyworth C, Epton T, Goldthorpe J, Calam R, Armitage CJ. Are healthcare professionals delivering opportunistic behaviour change interventions? A multi-professional survey of engagement with public health policy.

Implementation Science. 2018 Dec;13:1-9.

5. Daley, A.J. (2022) ‘Time to get our teeth into reducing obesity: Should dentists screen and deliver interventions to reduce obesity in the population?’. British Dental Journal, 232(2), pp. 78–79.

54 Clinical Effectiveness Bulletin May 2025

The effects of the COVID-19 pandemic on orthodontic treatment in a Dental Hospital and a District General Hospital: A service evaluation SJ Campbell (Post-CCST)¹, K Smorthit (Post-CCST)2, N Mandall (Consultant)3, T Hodge (Consultant)4 and C Bates (Consultant)3 University Dental Hospital Manchester1, Royal Blackburn Hospital2, Tameside General Hospital3, Leeds Dental Institute⁴ Background/Rationale The COVID-19 pandemic has significantly impacted dentistry and orthodontics, particularly in terms of waiting lists, treatment times, and patient care. In the United Kingdom (UK), efforts to contain the spread of the virus led to the suspension of routine dental care and elective procedures under general anaesthesia1,2. Enhanced infection control protocols, staff shortages, and the closure of many practices and secondary care departments, further disrupted the provision of care, resulting in extended waiting times for appointments and delayed treatment initiation for both new and existing patients3.

Orthodontic treatments, which rely on regular adjustments and close monitoring, faced substantial interruptions. These delays not only prolonged treatment durations but also increased the risk of complications such as treatment relapse, decalcification, and gingivitis⁴. Patient anxiety about attending hospitals and the need for both staff and patients to isolate further exacerbated the challenges⁵.

This project aimed to evaluate whether the pandemic caused measurable changes in treatment duration, the number of visits required, the involvement of multiple clinicians, or treatment outcomes as a result.

Aims and Objectives To assess the effects of the COVID-19 pandemic on orthodontic treatment at Tameside General Hospital and Leeds Dental Institute. This was assessed by: • • •

Measuring the treatment outcome from pre-treatment and post-treatment dental casts using the PAR index The time taken to complete treatment and the number of appointments required The number of treating clinicians

Standards/guidelines/evidence base • 90% of patients should complete treatment within 3 years • 90% of patients should achieve a % PAR reduction greater than 70% Although there are no official targets for PAR score changes in secondary care, the guidance for primary care outlined by NHS England 2015 were used6. At least 75% of cases should have a PAR score reduction >70% and 3% or less should have a PAR score reduction <30%⁶.

In the literature, no consensus has been reached about orthodontic treatment time. A recent

systematic review revealed a mean treatment time with fixed appliances of 19.9 months however, values ranged from 14 to 33 months⁷. Previous service evaluations in our department have found an average treatment duration of 24-30 months.

The aim would be that patients should not have an increase in treatment duration greater than the 3 months the departments were closed due to pandemic restrictions.

Sample and data source Thirty consecutive patients who completed treatment from April 2019 to February 2019 (pre-COVID) and 30 consecutive patients who completed treatment from April 2021 to May 2021 (post-COVID).

Audit type Retrospective service evaluation.

Methodology Inclusion and exclusion criteria: Inclusion: Comprehensive orthodontic treatment Exclusion: Cleft lip and or palate, craniofacial syndrome May 2025 Clinical Effectiveness Bulletin 55

Data collection:

Number of emergency appointments

Using a data collection proforma, the following information was extracted from patient notes:

Surprisingly the number of emergency appointments in the patients who were debonded prior to COVID was slightly more than the patients debonded after COVID. This may be due to hospital closures, whereby fewer emergency clinic appointments were available to patients.

In addition, comprehensive patient information resources were made available to allow patients to manage their own orthodontic emergencies remotely⁸.

•

Length of treatment. Start point was considered the bond up appointment and end point was recorded as the debond appointment Number of treating clinicians Number of visits in total including emergency appointments PAR outcome

• • •

Leeds Dental Institute Change in PAR (%)

Findings Tameside General Hospital Change in PAR (%)

Number of treating clinicians

Number of emergency appointments

Number of visits in total

Length of treatment (months)

T1

79.0%

2.6

2.6

22

31.5

T2

79.3%

3.9

1.6

23

39

Number of visits in total

Length of treatment (months)

T1

71.6

16

24.5

T2

77.4

15.3

32.1

Figure 1: Overall Results Tameside General Hospital

Figure 2: Overall Results Leeds Dental Institute

Impact on PAR

Impact on PAR

In the period prior to COVID (T1) overall the change in PAR was 79.0%, in the period after COVID (T2) the change in PAR was 79.3%. At T1 80% of patients had greater than 70% PAR change, with no patients having less than 30% change. At T2 83% of patients had greater than 70% PAR change with no patients having less than 30% change in PAR score.

In the period prior to COVID overall the change in PAR was 71.6%, in the period after COVID the change in PAR was 77.4%. At T1 70% of patients had greater than 70% PAR change with 7% of patients having less than 30% change. At T2 80% of patients had greater than 70% PAR change with 7% of patients having less than 30% change in PAR score.

Impact of the number of treating clinicians per patient

Impact on number of visits and treatment length

For debonds completed after COVID there was a slight increase in the number of treating clinicians per patient; 2.6 at T1 vs 3.9 at T2. This is likely as a result of the increased treatment time. In the period after COVID, ensuring patients were seen as soon as possible was prioritised over continuity of clinician. It is likely that staff sickness may also have had an impact.

The number of visits at each time point were similar, 22 at T1 vs 23 at T2. However the length of treatment was significantly different; 32.1 months at T2 vs 24.5 months at T1. The increased treatment time is to be expected due to hospital closure.

Despite the increased treatment time, the number of appointments were similar as patients could not be seen during hospital closure.

56 Clinical Effectiveness Bulletin May 2025

Observations Overall standards of care were maintained. Change in PAR was very similar, the number of clinicians were slightly increased to allow patients to be seen as soon as possible after reopening of the hospital and there was little difference in the number of emergency appointments. Best case scenario, treatment duration should have been increased by approximately 3 months to match the period of hospital closure for Tameside General Hospital, however an increase in 7.5 months was recorded and similarly an increase in 8 months was recorded for Leeds Dental institute. There are many factors that are likely to have contributed this. Overall there were restricted numbers in the amount of patients we could see due to standard operating procedures (SOP’s) put in place at this time. This included staggering numbers of patient on clinic and in waiting rooms to ensure appropriate social distancing. Many staff were still redeployed at the return of services and dealing with the resultant backlog of patients meant inevitably longer intervals between appointments.

Change in PAR (%)

Number of visits in total

Length of treatment (months)

T1

75.3

19

28

T2

78.35

19.15

35.55

Figure 3: Overall combined results Our observations are in line with other evidence looking into measurable changes in orthodontic care in the UK. Evidence showed treatment durations were extended due to prolonged intervals between appointments, as clinics operated at reduced capacity and prioritized emergency cases⁸. The involvement of multiple clinicians became more common, as staffing shortages and rotating shifts disrupted continuity of care, potentially impacting treatment outcomes3.

Despite these challenges, innovative solutions emerged, including the use of teleorthodontics, which allowed for remote consultations and monitoring⁹. While these technologies provided a temporary solution, they could not entirely replace in-person care, particularly for complex

cases requiring hands-on adjustments. Patient outcomes were affected, with many experiencing frustration, increased anxiety, and a decline in oral health due to delayed or inconsistent care⁵.

Recommendations It is essential to maintain robust contingency plans to ensure preparedness for any future national incidents or emergencies. This includes regularly reviewing and updating response strategies to adapt to evolving circumstances. Additionally, a commitment to upholding the highest standards of patient care must remain a priority, ensuring that services continue to be delivered safely, efficiently, and with a patient-centred approach. At this stage, there are no plans to conduct a further service evaluation; however, ongoing monitoring and assessment of service effectiveness will be important to maintain quality and efficiency.

Project involvement SJ Campbell K Smorthit N Mandall T Hodge C Bates References 1. Iacobucci G. Covid-19: all non-urgent elective surgery is suspended for at least three months in England. BMJ 2020; 368 :m1106 doi:10.1136/ bmj.m1106 2. Coulthard, P., 2020. Dentistry and coronavirus (COVID-19) - moral decision-making. British Dental Journal, 228(7), pp.503-505.

3. Guo, H., Zhou, Y., Liu, X. and Tan, J., 2021.

The impact of the COVID-19 epidemic on the utilization of emergency dental services. Journal of Dental Sciences, 16(4), pp.584-589.

4. Turkistani, K.A., Turkistani, A.N. and Turkistani, D.K., 2022. Impact of delayed orthodontic treatment on patient outcomes during the COVID-19 pandemic. International Orthodontics, 20(2), pp.348-356.

5. Ahmed, M.A., Jouhar, R., Ahmed, N., Adnan, S., Aftab, M., Zafar, M.S. and Khurshid, Z., 2021. Fear and practice modifications among dentists to combat novel coronavirus disease (COVID-19) outbreak. International Journal of Environmental Research and Public Health, 17(8), p.2821.

May 2025 Clinical Effectiveness Bulletin 57

6. NHS England, 2015. Guide for Commissioning Orthodontic Services. [online] Available at: https://www.england.nhs.uk [Accessed 23 January 2025].

7. Zahran S, McDonald F, Sherriff M. Efficiency and effectiveness of orthodontic treatment within United Kingdom secondary care: a service evaluation. J Orthod. 2018 Sep;45(3):169-175. doi: 10.1080/14653125.2018.1490871. Epub 2018 Jul 3. PMID: 29969080.

8. British Orthodontic Society. COVID-19 BOS Advice: Patients' Advice [Internet]. London: BOS; [accessed: 10 04 2024 ] Available from: https://bos.org.uk/cvid19-bosadvice/patients-advice/ 9. Suri, S., Vandersluis, Y.R., Kochhar, A.S., Bhasin, R. and Abdallah, M.N., 2020. Clinical orthodontic management during the COVID-19 pandemic.

The Angle Orthodontist, 90(4), pp.473-484. https://doi.org/10.2319/033120-236.1

58 Clinical Effectiveness Bulletin May 2025

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