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Scientific Section |
University Dental Hospital of Manchester, UK
Correspondence: Dr N. A. Mandall, Department of Oral Health and Development, University Dental Hospital of Manchester, Higher Cambridge Street, Manchester M15 6FH, UK. Email: mdtmsnam{at}fs1.den.man.ac.uk
Abstract
Aim: The aim of the study was to evaluate the reliability of a panel of orthodontists for accepting new patient referrals based on clinical photographs.
Sample: Eight orthodontists from Greater Manchester, Lancashire, Chester, and Derbyshire observed clinical photographs of 40 consecutive new patients attending the orthodontic department, Hope Hospital, Salford.
Method: They recorded whether or not they would accept the patient, as a new patient referral, in their department. Each consultant was asked to take into account factors, such as oral hygiene, dental development, and severity of the malocclusion.
Statistics: Kappa statistic for multiple-rater agreement and kappa statistic for intra-observer reliability were calculated.
Results: Inter-observer panel agreement for accepting new patient referrals based on photographic information was low (multiple rater kappa score 0.37). Intra-examiner agreement was better (kappa range 0.34–0.90).
Conclusion: Clinician agreement for screening and accepting orthodontic referrals based on clinical photographs is comparable to that previously reported for other clinical decision making.
Key words: Clinical photographs, consultant reliability, inappropriate referrals, new patient referrals
Introduction
This study was designed to investigate the reliability of orthodontists in accepting new patient referrals based on clinical photographs. The main aim was to assess whether photographic records might reliably be used for a teledentistry system to screen inappropriate referrals.
The data reported is in addition to a randomized clinical trial that is being carried out to assess the validity of a teledentistry system for screening orthodontic referrals. Currently, patients are being referred through a ‘store and forward’ teledentistry link, and later being evaluated clinically, to assess whether the same decision to accept the referral is made.
Teledentistry is becoming an increasingly important tool in clinical dentistry.1–
4 It combines computer and telecommunications technology with medical expertise to enable health professionals to send and receive information, and provide diagnostic and consulting services from locations distant from their patients.5
One problem with the UK orthodontic services is long waiting lists for the first consultation appointment. For example, Russell et al. 6 reported an average wait of 4.6 months (range 0–24 months+). Additionally, 45% of new orthodontic referrals have been shown to be inappropriate7 and this must contribute to the long new patient waiting lists.
The latter study also revealed that the commonest reasons for inappropriate referrals were mild malocclusion, poor oral hygiene, and timing of referral. It could be suggested that these factors are detectable from electronically transferred clinical photographs only, particularly, since the use of full records has not been shown to make large differences to clinical decision making.8 Therefore, the aim of this study was to evaluate the reliability of a panel of consultant orthodontists for acceptance of new patient referrals based on clinical photographs.
Sample
Forty consecutive orthodontic patients attending a new patient clinic at Hope Hospital, Salford agreed to have clinical photographs taken at the end of their consultation appointment. Eight consultant orthodontists from Greater Manchester, Lancashire, Chester, and Derbyshire comprised the assessment panel.
Methods
Photographic material
The 40 new patients comprised a mixture of those who were suitable for treatment and those who were not because of poor oral hygiene, mild malocclusion, or referral that was too early. The colour clinical slides for each patient were mounted for viewing on light boxes. Each patient had full face and profile, labial, and right and left buccal views in occlusion, and upper and lower occlusal views.
Panel of consultant orthodontists
Each orthodontist was asked to indicate whether or not they would accept the patients as new referrals with a view to either (i) starting treatment straight away, (ii) providing a treatment plan, or (iii) giving advice to general dental practitioners. It was emphasized that this was meant as a screening process only and factors, such as oral hygiene, severity of malocclusion, and timing of the referral were to be considered. The decision was made based on the orthodontists' usual clinical practice, rather than use strict referral guidelines. The following additional information was provided:
Intra-examiner reliability
Each orthodontist viewed the same series of photographs, on the second occasion, at least 2 weeks after the initial assessment. They re-recorded whether they would accept the patient for treatment, treatment plan or advice.
Statistics
Kappa statistic for the outcome variable, for multiple raters, was calculated using ‘Stata’ software (Stata Corporation, Texas). Kappa statistic was used to assess intra-examiner reliability.
Results
The multiple-rater kappa score (inter-consultant reliability) for acceptance of an orthodontic referral was 0.37. Kappa scores for intra-consultant reliability ranged from 0.34 to 0.90 (Table 1).
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The results suggest that reliability between consultants for accepting an orthodontic referral based on photographs was low. However, agreement was generally better for the same clinician over time. Nevertheless, the values reported are comparable with other published literature and these are shown in Table 2. There may be several reasons for the findings in this study, which may be summarized as:
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Clinic policy.
In this series of patients, there were some adults with fairly severe malocclusion that would require routine orthodontics only. Some consultants worked in hospitals that only accept adults if they required inter-disciplinary treatment.
The extent of formal use of orthodontic indices.
The widespread use of the Index of Orthodontic Treatment Need (IOTN)9 has helped to prioritize patients with high or definite need for treatment on aesthetic or dental health grounds. It is possible to screen new patients using the aesthetic component of IOTN from clinical photographs alone. However, the rigorous application of the dental health component of IOTN to clinical photographs is not possible, even though additional information, such as overjet was provided.
Individual clinician variability.
Since full use of IOTN to screen new patients using clinical photographs is impossible, it is likely that a degree of clinician judgement will be used in these cases.
The severity of the cases presented.
Lee et al.10 suggested that agreement may be lower between orthodontists if the variables that were being examined were mild. Within this sample, however, there was a range of malocclusion and this is unlikely to account, in isolation, for the low inter-examiner agreement.
Conclusions
Clinician agreement, for screening and accepting orthodontic referrals based on clinical photographs, is comparable to that previously reported for other clinical decision making.
References
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2 Hayawaka Y, Farman AG, Eraso FE, Kuroyanagi K. Low cost teleradiology for dentistry. Quintessence International, 1996; 27: 175–178.[Medline]
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8 Han UK, Vig KWL, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop 1991; 100: 212–219.[Medline]
9 Brook P, Shaw WC. The development of an index of orthodontic treatment priority. Eur J Orthod 1989; 11: 309–320.
10 Lee R, MacFarlane T, O'Brien K. Consistency of orthodontic treatment planning decisions. Clin Orthod Res 1999; 2: 79–84.[Medline]
11 Baumrind S, Korn EL, Boyd RL, Maxwell R. The decision to extract: Part I – Interclinician agreement. Am J Orthod Dentofacial Orthop 1996; 109: 297–309.[CrossRef][Medline]
12 Ribarevski R, Vig P, Vig KD, Weyant R, O'Brien K. Consistency of orthodontic extraction decisions. Eur J Orthod 1996; 18: 77–80.
13 Luke LS, Atchison KA, White SC. Consistency of patient classification in orthodontic diagnosis and treatment planning. Angle Orthod 1998; 68: 513–520.[Medline]
Received November 29, 2000; accepted June 14, 2001
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