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Scientific Section |
University of Bristol, UK.
Correspondence: Professor C. D. Stephens, University of Bristol Dental School, Lower Maudlin St, Bristol BS1 2LY, UK. Email c.d.stephens{at}bristol.ac.uk
Abstract
Objective: To determine UK orthodontic consultants' attitudes to the provision of orthodontic advice to general dental practitioners by electronic means.
Design: Questionnaire.
Setting: Conducted by email and surface mail as appropriate in August 2000.
Subjects: All those UK NHS orthodontic consultants contained in the membership lists of the Consultant Orthodontists Group of the British Orthodontic Society.
Outcome: An 86 per cent response was obtained from the 231 consultants.
Results: More than half (58 per cent) of the consultants were interested in providing an electronic diagnostic service for the general dental practitioners in their locality and 70 per cent were in favour of further research into this possibility. Provided this was mediated through their GDP, only 26% would oppose consultant advice being given electronically from a centralized source.
Conclusions: A majority of UK orthodontic consultants support the concept of using teledentistry to make their advice more accessible to dentists and patients.
Key words: Orthodontic diagnosis, orthodontic referral, telemedicine
Introduction
The aims of the undergraduate orthodontic curriculum would appear to be broadly similar in the UK, Europe, and N America1–
3. These may be summarized as being the recognition of malocclusion, and knowing what when and where to refer. Sadly, the evidence suggests that these aims have never been fully achieved in the majority of graduates.4–9 In the UK, unlike many parts of Europe, dental specialties have been slow to develop outside dental schools. Because of this and because the UK has, until recently, had few trained orthodontic specialists, the general dental practitioner in the past had an important contribution to make in the delivery of UK orthodontic care. For that reason, the UK General Dental Council's recommendations on the orthodontic undergraduate curriculum graduate also include the teaching of those skills necessary to plan and carry out simple orthodontic treatment.1 Here, too, there is evidence that this requirement is not being met10–11 and the University Teachers Group of the British Orthodontic Society has recently urged the General Dental Council to remove this requirement from its recommendations in the undergraduate curriculum.12
Increasing numbers of orthodontic specialists in the UK and the deployment of orthodontic therapists should reduce the need for general dental practitioners (GDPs) to provide orthodontic treatment in the future, but their freedom to be able do so is likely to remain. In addition, the role of the GDP in initiating referral will remain and will continue to be the key to the effective use of specialist orthodontic services.
In theory, general dental practitioners working within the UK National Health Service can obtain free advice from their local consultant orthodontist to assist them in orthodontic case selection and treatment planning. The consultant service was established in 1950 to support the delivery of orthodontic care within the newly established National Health Service. There are now 231 consultants in the UK who are based in most of the major hospitals. These are salaried appointments and represent the highest grade of specialist working within the NHS. Those successful in obtaining a consultant appointment enjoy complete equality of status with their medical and surgical colleagues, and will have completed at least 8 years postgraduate training, of which at least 5 will have been in full time orthodontic training.
Consultant orthodontists have three main functions:
The emphasis on each one of these depends very much on local circumstances and in particular the availability of local orthodontic specialists.13 In addition, the consultant takes a leading role in coordinating orthodontic services in his catchment area. He or she also provides an independent expert clinical opinion in cases of dispute concerning treatment need or treatment outcome. Because consultants are relatively evenly distributed throughout the UK, no patient should have to travel more than a few miles to obtain a consultant opinion and over 90 per cent of such patients are seen within 13 weeks.13
However, despite the fact that specialist consultant advice is available to the general dental practitioner only a small number of GDP orthodontic patients receive it.14 This is unfortunate, since many incorrect planning decisions are made by GDPs.15 At the same time, a high proportion of referrals made to UK orthodontic consultants are judged to be inappropriate16–17 and this adds unnecessarily to consultant waiting lists.18
Over the years various approaches have been tried by consultants to improve matters, but none as yet has been shown to have had any real effect.19–21 The essential question is how to make specialist advice on orthodontic case selection and treatment planning more accessible to the general practitioner in such a way as he or she will find it easier to use than to ignore.
Advances in telemedicine have been shown to offer a way of addressing this issue that applies equally to medical specialties. For example successful demonstrations of remote diagnosis have been reported in dermatology, otolaryngology, ophthalmology, and accident and emergency services.22–25 As a recent pilot study suggests that the same would be true in orthodontics26 this survey was undertaken to determine if UK consultants would support the concept of advice being provided in this way to UK GDPs.
Method
In the Autumn of 2000 a questionnaire was sent to all 231 UK orthodontic consultants (Figure 1). This questionnaire, which included supporting references not included in Figure 1, was structured to provide information, which would be helpful to the specialty in the light of the UK Government's initiatives in Information Technology, and its commitment to improving patient access to healthcare information.27 Those 158 consultants (68.2. per cent) who were known to have access to email were contacted by this means. The remaining 73 were sent the same questionnaire by surface mail. Reminders were sent to those who had not replied. Those approached by email were recontacted after 1, 2 and 3 weeks. The remainder were sent a postal reminder after 3 weeks.
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An 86 per cent response was obtained (199 useable replies). The 158 email requests yielded 119 replies (75.3 per cent response), but 10 email addresses were not recognized and so 80.4 per cent would be a truer rate of response. A 25 per cent email response was received within 24 hours and a 41 per cent response within 7 days. The postal response was 93 per cent (68 replies), but included some postal replies to an original request sent by email. This appeared to be because a few consultants wished to preserve their anonymity, which is impossible with an emailed reply. Also it appeared that some consultants dealt with their emails by annotating hardcopies. Eighty respondents (40 per cent) said they had been present at the meeting 6 months earlier when teledentistry advice had been demonstrated.
The responses to the questions are summarized in Figures 2–6. A high percentage (70 per cent) were in favour of further research into providing advice by electronic means and 59 per cent of consultants were interested in running such a service for the general dentists in their locality (in fact, two consultants were already providing this). The difference between the two figures represents those concerns that were raised in the free text section of the questionnaire. These were:
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Half the consultant body supported the idea of a national advice service run by the Consultant Orthodontists Group (50 per cent) and only 26 per cent opposed. Question 4 had been included because the Government had recently announced its interest in applying the Index of Orthodontic Treatment need to all NHS treatment.28 A number of consultants were concerned that they might well be inundated with cases where the dentist felt that the threshold for NHS treatment need had not been reached, but where the parent wanted a second opinion on this decision. It seemed to the authors that teledentistry might well provide and effective way of dealing with such cases through a central facility, which would depersonalize such decisions. It will be seen that 50 per cent of consultants would support dentists having access to central advice for their patients, but 31 per cent opposed this. Only 26 per cent would support direct patient access to such a service and 50 per cent were opposed to this idea.
The data were also analysed according to the age group of the respondent (34–45 years, 46–55 years, 56–65 years), whether the respondent had email or not, and whether they were present at the annual meeting of orthodontic consultants held 6 months earlier where the authors had described and demonstrated a teledentistry referral system. Surprisingly, in all analyses no significant difference was found in the distribution of the responses between groups (Chi square test, P > 0.05).
Discussion
There have been very few reports of the application of telemedicine to the field of dentistry. This is surprising because many successful applications have been described in other outpatient based specialties.22–24 Telemedicine techniques would also appear to be applicable in the delivery of continuing professional education29 and the dissemination of standardized clinical audit records, such as those used in the orthodontic CASES project.30
Conclusions
The majority of UK orthodontic consultants were in favour of developing telemedicine techniques to provide orthodontic advice to general practitioners. There appears to be no reason why these methods should not be used by orthodontists in other countries to obtain second opinions from their specialist colleagues and to provide immediate advice to referring general practitioners. Telemedicine techniques may also have a role in facilitating continuing professional education and clinical audit in orthodontics.
Acknowledgments
The authors would like to than all members of the Consultant Orthodontist Group and in particular Mr N. W. T. Harradine and Mr N. E. Carter without whom this survey would not have been possible.
References
1 General Dental Council. Recommendation on the undergraduate curriculum: the first 5 years. GDC, London, 1997.
2 Adamidis JP, Eaton KA, McDonald JP, Seeholzer H, Sieminska-Piekarczyk B. A survey of undergraduate orthodontic education in 23 European countries. J Orthod 2000; 27: 84–91.
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12 University Teachers Group of the British Orthodontic Society. Submission to the General Dental Council. London: British Orthodontic Society, 2001.
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18 Willmot DR, DiBiase D, Birnie DJ, Hesterman RA. The Consultant Orthodontists Group survey of hospital waiting lists and treated cases. Br J Orthod 1995; 22: 53–57.[Abstract]
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22 Loane MA, Corbett R, Bloomer SE, et al. Diagnostic accuracy and clinical management by real-time teledermatology. Results from the Northern Ireland arms of the UK multicentre teledermatology trial. J Telemed Telecare 1998; 4: 495–500.
23 Made C, Carle L, Soderberg O, Hellstrom S. Tele-otolaryngology consultations between two rural primary care centres in southern Lapland and the University of Umea. J Telemed Telecare 1998; 5(Suppl 1): 93–94.
24 Lamminem H, Salminen L, Uusitalo H. Teleconsultations between general practitioners and ophthalmologists in Finland. J Telemed Telecare 1999; 5: 118–121.[Medline]
25 Benger J. A review of minor injuries telemedicine. J Telemed Telecare 1999; 5(Suppl 3): 5–13.
26 Cook J, Mullings C, Vowles R, Ireland R, Stephens CD. Providing on-line orthodontic advice: an evaluation of a teledentistry system and a protocol for its use. J Telemed Telecare 2001; 7: 334–337.[Medline]
27 Department of Health. Information for Health: an information strategy for the modern NHS 1998–2005. London: DoH, 1998.
28 Department of Health. Modernising NHS Dentistry. London: DoH, 2000.
29 Kingsnorth AN, Campbell JK, Vranch A. Teleteaching—a practical and economical; method of delivering surgical; education. Ann R Coll Surg Eng 1999; 82: 66–70.
30 Clark JD, Kerr WJS, Davis MH. CASES—clinical audit; scenarios for evaluation and study. A national audit and continuing-education programme based on six orthodontic patient-management problems Br Dent J 1997; 183: 108–111.[Medline]
Received July 12, 2001; accepted August 28, 2001
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