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OCCLUSION CHARACTERISTICS OF PRIMARY DENTITION BY AGE IN A SAMPLE OF SAUDI PRESCHOOL CHILDREN.

Byline: LAILA BAIDAS - Email: lbaidas@ksu.edu.sa

ABSTRACT

The aim of this study was to describe occlusion characteristics of primary dentition by age in a sample of Saudi children aged 3-5 years. By using standardized and validated recording criteria, a single operator measured (the primary molar and canine relationships, overjet, overbite, anterior open bite, and anterior and/or posterior crossbites), in 323 Kindergarten children (49.7% boys and 50.3% girls).

Descriptive and comparative (Chi-square, t-test) statistics, were used to investigate the occlusal relationship by age of the children. In terms of the molar relationship; flush terminal plane was present in 75% of the children followed by mesial step (13.9%) and distal step (11.1%). The canine relationship was Class I in 90.1% of the sample, followed by Class III (7.4%), and Class II (2.5%) relationship. Fifty seven percent of the children had normal overbite, with significantly higher percentage in older children. Open bite tendency was greater in younger children. Fifty two percent of the children had an overjet between 0-2 mm, 30.3% ranged between 2.1-4 mm, 15.8% >4 mm, and only 1.9% had reverse overjet. Posterior crossbite was present in 8.7% of the children examined. The differences and correlations between the age and the occlusal relationships were not significant. The prevalence of malocclusion was found to be less than those reported in other populations

INTRODUCTION

The occlusal relationship in deciduous dentition is known to have an important bearing on the establish-ment of the normal occlusal relationship in the perma-nent dentition.1 Studies on the occlusion of primary dentition have been carried out widely among children with different age groups in various regions of the world.2-12 Few such studies have been published in Arab population including Saudi, and Jordanian chil-dren.13-14 These studies revealed that the characteris-tics of primary dentition varied among population and ethnic groups. Several studies2,3,6 found that the most prevalent occlusal molar relationship in primary den-tition in North American children was flush terminal occlusion.

Nanda et al4 conducted a study on Indian children and found that the normal occlusal patterns for the deciduous dentition were class I and class III molar and canine relationships. The frequency of class I molar and canine relationship decreased with in-creased age, whereas those with class III increased with age. In Is aeli preschool children5, flush terminal occlusion was reported to be 2.4 times more frequent than the mesial step occlusion.

Kisling and Kerbs7 studied the occlusion in 3-year-old children living in Copenhagen. Open bite was found much more fre-quently in children with maxillary overjet greater than 4 mm. Valente and Mussolino8 assessed the distribu-tion of overjet, overbite and open bite in deciduous dentition in Brazilian white children, and they con-cluded that the degree of overjet and open bite de-creased with the increasing age of the children. Kabue et al9 found that the straight terminal plane of the deciduous second molars was presented in 53% of the Kenyan children, mesial step in 43% and distal step occlusion in one percent; he concluded that more than half of the children were found to have some form of malocclusion. Ferreira et al11 stated the most preva-lent occlusal relationship between primary canine and primary molar among Brazilian children was class I.

Otuyemi et al10 found that 74.5 % of the three to four year old Nigerian children had class I primary second 1 Assistant Professor, Division of Orthodontics, Department of Pediatric Dentistry and Orthodontics, King Saud University College of Dentistry, Riyadh, Saudi Arabia molar relationship, 1.9% class II relationship and 20.9% class III relationship. They also observed that primary canine relationship was class I in 73.3% of the children, class II in 3%, and class III 14.7%.

Yilmaz et al12 evaluated the primary canine and the primary molar relationship in three to six year-old Turkish children. The rate of ending on Flush terminal plane in primary second molar, and class I primary canine occlusion were stated to be the highest.

They also found positive correlation among different age groups and both the canine and molar relationships. Farsi, and Salama13 conducted a study among 3-5-year-old Saudi children, finding that majority of the children had flush terminal relationship and Class I canine relationship, followed by mesial step and class II rela-tionship.

The degree of overbite was significantly less in the 5-year-olds than in the 3-year-olds. The majority of their sample had an overjet of 0-2 mm, and that overjet of 2-3 mm was significantly lower in the older age group. Anterior and posterior crossbite were found in 2% and 4% respectively. In a study conducted by Abu Alhaija, and Qudeimat14 among 3-6 years Jordanian children, mesial step molar relationship was found in 47.7% of children followed by flush terminal molar relationship in 37% and distal step in 3.7%. Class I canine relationship was found in 57% of children, followed by 29% Class II and 3.7% Class III. Normal overbite was seen in 44.3% of the children. Posterior and anterior crossbite was seen in 7% and 11.8% of the sample respectively.

The above mentioned studies show that the char-acteristics of primary dentition vary among different populations. The status of primary occlusion also af-fects the development of permanent occlusion.1 Baume2 reported that the primary dentition remains unchanged until the first permanent molar begins to erupt. Nanda et al4 and Bishara et al16 found high percentage of children with distal step in primary dentition proceed to develop Class II molar relation. However, Infante17 claimed that the class II occlusion in primary dentition decrease from 2 to 6 years of age. Nanda et al4 stated that there was an increase in prevalence of Class III occlusion with age. This brief review indicates conflict-ing findings. The aim of the present study was to investigate the occlusal relationship characteristics of primary dentition by age in a group of 3-5 year old Saudi children.

METHODOLOGY

A cross sectional study was conducted through clinical examination and completion of a simple ques-tionnaire. The study sample consisted of 323 Saudi children aged 3-5 years, attending 8 Kindergartens which were randomly selected to represent the four academic regions of Riyadh city, the capital of Saudi Arabia. Letters explaining the nature of the study and informed parental consent for the child's participation were sent to the parents through school's principal, in addition to the questionnaire inquiring about child's age, gender, medical history, past or present non-nutritive sucking habits (yes/no), and previous orth-odontic treatment (removable appliance, expansion etc). Children with past or presence sucking habits were excluded from the study.

All children were assessed while sitting in an up-right position and biting in maximal intercuspation, using pen light, mouth mirror, metal millimeter rul-ers, gloves and masks in compliance with the interna-tional standards of infection control protocol. The criteria of Foster & Hamilton15 were used for defining the occlusion Dental examination of children Clinical evaluation was performed on all Saudi children in a classroom setting based on the following criteria:

- Signed informed consent form.

- Child aged between 3-5 years.

- Health and age-appropriate intellectual develop-ment (within normal limit).

- Presence of all 20 deciduous teeth with no erupted permanent teeth.

- No missing primary tooth.

- No sucking habit.

- Free of carious lesions that could result in de-creased arch length.

- No previous orthodontic treatment.

Evaluation criteria

1 Terminal plane relationship

* Flush terminal plane: The distal surfaces of maxillary and mandibular primary second molars lie in the same vertical plane in centric occlusion.

* Mesial step: The distal surface of the mandibu-lar primary second molar is mesial to that of the maxillary primary second molar in centric occlusion.

* Distal step: The distal surface of the mandibu-lar primary second molar is distal to the distal surface of the maxillary primary second molar in centric occlusion.

2 Primary canine relationship

* Class I: The cusp tip of the maxillary primary canine tooth is in the same vertical plane as the distal surface of the mandibular primary ca-nine.

* Class II: The cusp tip of the maxillary primary canine tooth is mesial to the distal surface of the mandibular primary canine.

* Class III: The cusp tip of the maxillary primary canine tooth is distal to the distal surface of the mandibular primary canine. In the determination of primary second molar relationship, if one side ends with distal or mesial step while the other side ends with flush terminal plane, it was recorded as flush terminal plane. In the determi-nation of canine relationship, if there was a Class II or Class III relationship on one side and a Class I on the other, it was recorded as a Class I relationship. In the determination of the occlusal relationship of both primary second molars and primary canines, the chil-dren with mesial step on one side and distal step on the other were left out of assessment.

3 The degree of overbite was recorded as

* Normal: the upper primary central incisors covering of less than or equal to 50% of lower primary incisors in centric occlusion

* Increased: the upper primary central incisors covering of more than 50% of lower primary incisors in centric occlusion

* Edge-to edge upper and lower primary incisors relation

* Anterior open bite: there is no vertical overlap between upper and lower primary incisors in centric occlusion.

4 Overjet: Amount of overjet measured from the lingual surface of the mesial corner of the most pro-truded maxillary incisor to the facial surface of the corresponding mandibular incisor recorded in millime-ters.

5 Anterior crossbite: One or more of the maxil-lary incisors occluded lingual to the opposing mandibu-lar incisors in centric occlusion.

6 Posterior crossbite: One or more of the maxil-lary primary canine or molars occluded palatally to the buccal cusps of the opposing mandibular teeth in centric occlusion (either unilateral or bilateral).

Examiners reliability: An orthodontist performed all dental examinations in order to avoid inter-operator bias. Examiner reliability was checked through an assessment of the occlusal characteristics of 20 orth-odontic study models which had been trimmed in their centric occlusion relationship, on two occasions sepa-rated by at least two weeks.

Statistical analysis: Data were collected and entered into computer utilizing FoxPoro Program for Win-dows. Statistical Package for Social Sciences (SPSS version 13) was utilized for all statistical computations. Frequency distribution was used for the descriptive analysis. A chi-square test was used to compare the proportions of different occlusal characteristics among different age groups. Paired t-test was used to deter-mine the differences of occlusal characteristics within the same age group. The significant level was set at 0.05.

RESULTS

The intra-examiner reliability test showed a high level of agreement (kappa statistic 0.90). Table 1 shows the distribution of children examined in term of age and gender. The study sample consisted of 49.7 % boys and 50.3% girls. Boys and girls were pooled in each age group as there were no significant differences between them with respect to occlusion.

Out of the 323 children examined, 75% had flush terminal plane, 11.1% distal step and 13.9% mesial step molar relation. Table 2 shows the percentage and correlation of the occlusal relationship of primary second molar for every age group. The flush terminal plane was the most predomi-nant molar relation for each age group. It was observed that the molar relation with mesial step was 13.9 % in 3 years olds, 13.1 % in 4 years olds and 11.5 % in 5 years olds. When the groups were compared in pairs, no statistical significant difference was found (P>0.05). There was slight decrease in the proportion of children with distal step from age 3-5 years old 11.1%, 7.6% respectively, but the differences in their occurrence was not statistically significant. When the ages of the children were compared regarding the primary second molar relationship, it was found that the differences was not significant and no association (P=0.524) was found between different terminal plane relationship and age group.

Regarding canine relationship, it was found that 90.1% of the children had Class I, 7.4% Class III, and 2.5% Class II relationship. Table 3 shows the percent-age and correlation of occlusal relationship of canine for every age group. The most common primary canine relationship was observed to be Class I relationship, no statistically significant difference was found between different age groups. Class II canine relation was not observed at 3 years of age. However in children 4-5 years olds, it showed fluctuation.. Class III canine relationship among 3 and 5 year olds were found to be higher than in children aged 4 years. However, when the groups were compared in pairs, the difference were not statistically significant at (P> 0.05). Similar to relationship in primary molars, the differences between the primary canine relationship also showed no association with age (P=0.456).

The results indicate that 57% of children had normal overbite, 28.8% increased overbite, 7.1% edge-to-edge, and 7.1% anterior open bite. The distribution of overbite by age is presented in Table 4. The percent-age of children with normal overbite increased signifi-cantly from age 3 to 5 years (P=0.03), and from age 3 to 4 years (P=0.029). The increased overbite percentage decreased in older age group. The overall differences between the various age groups were not statistically significant. Open bite tendency, represented by edge-to-edge relationship and anterior open bite combined together was greater in the younger age group than the older age group.

The majority of children (52.3 %) had an overjet between 0-2 mm followed by >2-4 mm (30.3 %) and >4mm (15.8%); only 1.9 % of the children had reverse overjet. Overjet ranged from 0 to 7 mm with a mean of 1.9 mm. Increased overjet ( e" 6 mm) was observed in 1% of the sample. Table 5 shows the distribution of overjet among the sample by age. There was slight reduction in the prevalence of Increased overjet (>4mm) with age, but it was not statistically significant. Ante-rior crossbite was found only in six children (1.9%), the number of children in each age group were too small to permit any valuable comparison with age.

TABLE 1: DISTRIBUTION OF CHILDREN IN TERMS OF AGE AND GENDER

Age###Girls###Boys###Total

(Years) No. (162)###% No. (161)###% No. (323)###%

3###17###10.5###19###11.8###36###11.15

4###65###40.1###65###40.4###130###40.25

5###80###49.3###77###47.8###157###48.6

TABLE 2: OCCLUSAL RELATIONSHIP OF PRIMARY SECOND MOLAR BY AGE

###Second Primary Molar Relationship###

Age###Flush Terminal Distal Step (30) Mesial Step (40) Total###P-value

Years###Plane (253)###

###No.###%###No###%###No###%###No

3###27###75###4###11.1###5###13.9###36###0.524

4###99###76.2###41###10.8###17###13.1###130

5###127###80.9###12###7.6###18###11.5###157

TABLE 3: OCCLUSAL RELATIONSHIP OF PRIMARY CANINES BY AGE

###Canine Relationship###

Age###Class I (291)###Class II (8)###Class III (24)###Total (323)###P-value

Years No###%###No###%###No###%###No###

3###33###91.7###0###0###3###8.3###36###0.456

4###119###91.5###5###3.8###6###4.6###130###

5###141###89.8###3###1.9###13###8.3###157###

TABLE 4: VERTICAL INCISOR RELATIONSHIP BY AGE###

###Degree of Overbite###

Age###Normal###Increased###Edge-to-edge###AOB###Total###P-value

(Years) (184)###(93)###(23)###(23)###(323)###

###No###%###No###%###No###%###No###%###No

3###15###41.7###14 38.9###2###5.6###5###13.9 36###0.180

4###77###59.2###40 30.8###7###5.4###6###4.6 130###

5###92###58.6###39 24.8###14###8.9###12###7.6 157###

AOB: Anterior Open Bite###

TABLE 5: DEGREE OF OVERJET BY AGE###

###Degree of Overjet (mm)###

###-1 to -2###0 to 2###>2 to 4###>4###Total###P-value

Age###No###%###No###%###No###%###No###%###No###

(Years) (6)###(169)###(98)###(51)###(323)###

###3###2###5.7###17 45.9###11 29.7###7 18.9###36###0.25###

###4###0###0###69 53.1###39###30###22 16.9###130###

###5###4###2.5###83 52.9###48 30.6###22###14###157###

TABLE 6: POSTERIOR CROSSBITE BY AGE

###Posterior Cross-bite###

Age###P-

(Years)###Bilateral###Unilateral###Total###value

###No###%###No###%###No

3###1###2.9###3###8.8###4###0.322

4###2###1.6###6###4.7###8

5###7###4.5###9###5.8###16

Twenty-eight children (8.7%) presented with poste-rior crossbite. Only 3% had bilateral crossbite, and 5.7% exhibited unilateral crossbite. Table 6 presents the distribution of posterior crossbite. Unilateral crossbite was higher in 3 years old children, whereas the bilateral crossbite was higher in 5 years old children. There were no significant differences in the prevalence of posterior crossbite in different age groups.

DISCUSSION

The present study investigated the occlusal rela-tionship characteristics of primary dentition in 3-5 years old Saudi children. Normal occlusal relation-ships of the primary dentition parallel those in perma-nent dentition. The development of malocclusion starts from the primary dentition, so it is very important to know the occlusion in the primary dentition, as well as the changes of occlusal pattern during the period of deciduous dentition. Several epidemiological studies have assessed the occlusion of primary dentition among preschool children in different population of the world2-12, few of which have been conducted in Arab countries.13,14

In the present study, most of the children (75%) had flush terminal plane molar relation, which was consis-tent with the findings of several previous studies.1,6,10,12,13 The normal molar relation of primary dentition is flush terminal plane until the eruption of the permanent first molars.3 However other investigators4,2 report that flush terminal plane or mesial step molar relation-ship are both normal and our result support this finding. The findings of this study showed a slight reduction in the prevalence of mesial step molar rela-tion from 13.9% in age 3 years to 11.5% in age 5 years. The findings did not coincide with the views of Ravan6 and Nanda et al4 who observed increase in the Class III relationship of molars with age. However Baume2, and Clinch3 reported that molar termination pattern re-mained unchanged through the primary dentition stage.

The prevalence of distal step was 11.1 %. There was a reduction in the prevalence of "distal step" from three to five years old children. The reduction in the preva-lence of "distal step" was in agreement with previously reported studies1,10,13. The age changes in the terminal plane relation of the molar results from a combination of mesial migration of the lower arch and a mesial shift of the mandible, which is probably caused by growth.4

Considering the canine relationship, the most common occlusal relationship was found to be Class I relation (90.1 %) . The prevalence of Class II canine and Class III canine relationship was 2.5% and 7.4% respectively. Class II canine relationship was not observed at 3 years of age.

In four and five years old children, a significant decrease in the Class II canine relationship was ob-served. An increase in the Class III canine relationship was observed with age, but it was not statistically significant. The most common canine relationship has been found to be Class I in various ethnic groups,6,10-14 which is consistent with our findings.

In our study, the prevalence and frequency of Class II and III canine relationships were consistent with the findings of Qtuyemi et al10 but not with the findings of some other studies.11,12-14 The differences in research methods used in assessing the prevalence of malocclusion should be considered when comparing various studies. In the present study, the prevalence of distal step molar relation and Class II canine relationships were lower than those reported by other studies, since all children with sucking habit were excluded from the present sample. In addition to, the prevalence of terminal plane and canine relationship were based on bilateral occur-rence.

The prevalence of normal overbite was observed in 57% of children, 7.1% had an edge-to-edge, and 7.1% had an anterior open bite. Increased overbite was found in 28.8% of the sample with lower prevalence in 5 years-olds than 3 years-olds. These findings were consistent with previous studies.10,13,14 The finding of the present study showed that the normal overbite increased significantly from younger to the older age. The age changes in overbite are probably caused by downward growth of the mandible. A higher incidence of anterior open-bite was found in 3 year olds compared to 5 year olds, which coincide with the findings of Farsi and Salama.13

The present study revealed that 52.3% of children had overjet ranged between 0 to 2 mm, 30.3% between >2 to 4 mm and in 15.8% more than 4 mm. The present findings were in accordance with those reported by Farsi and Salama13, but slightly lower than the study on Nigerian children by Qtuyemi et al10 who reported ideal overjet in 68.7% children, increased overjet in 14.7% and reduced overjet in 9.7 % children. There was a slight decrease of overjet with age, which was consis-tent with the studies by Nanda et al4 and Farsi and Salama.13 The age changes in overbite and overjet could result because of the growth of the mandible in both anterior-posterior, and vertical direction.4

The prevalence of posterior crossbite was 8.7%, which was in accordance with that reported by Abu Alhaija and Qudeimat14 (7% for Jordanian children), and Infante1 (7.1% for the white children), but higher than that reported by Qtuyemi et al10 (4.8% in Nigerian children), and Farsi and Salam11 (4% in Saudi children). Keruso18 suggested ethnic difference in the prevalence of posterior crossbite. He reported that crossbite was more frequent in Finish than Black African children. Infante17 also reported that the prevalence of posterior crossbite was significantly greater in White children than Black and Indian Children.

The present investigation attempted to provide an insight into pattern of occlusal relationships in primary dentition of Saudi children. Future longitudinal stud-ies are needed to follow up the dental development of children to observe the changes that may occur during the transitional period of the dentition.

CONCLUSIONS

Our findings indicate the following:

1 There were no gender differences in Saudi children in terms of occlusal relationship characteristic of primary dentition.

2 The flush terminal plane and Class I canine rela-tionships were the predominant occlusal relation-ship.

3 The percentage of children with normal over-bite was higher in younger children. Open bite tendency was also greater in younger children.

4 More than half of children had normal overjet.

5 The prevalence of anterior and posterior crossbite was 1.9% and 8.7% respectively.

REFRENCES

1 Infante PF. Malocclusion in the deciduous dentition in white, Black, and Apache Indian children. Angle ortho. 1975; 45: 213-18.

2 Baume LJ: Physiological Tooth Migration and Its Significance for the Development of Occlusion: I. The Biogenetic Course of the Deciduous Dentition. J Dent Res 1950; 29:123-32.

3 Clinch, L.M.: An Analysis of Serial Models Between Three and Eight Years of Age. Transactions of the British Society for the Study of Orthodontics 1957:13-31.

4 Nanda RS, Khan I, Anand R. Age changes in the occlusal pattern of deciduous dentition. J Dent Res. 1973; 52(2): 221-24.

5 Kaufman A, Koyoumdjisky E. Normal occlusal patterns in the deciduous dentition in preschool children in Israel. J Dent Res. 1967; 46(3):478-82.

6 Ravn JJ. Occlusion in the primary dentition in 3-year-old children. Scand J Dent Res. 1975; 83(3):123-30.

7 Kisling E, Krebs G. Patterns of occlusion in 3-year-old Danish children. Community Dent Oral Epidemiol. 1976; 4(4): 152-59.

8 Valente A, Mussolino ZM. Frequency of overjet, overbite and open bite in the deciduous dentition. Rev Odontol Univ Sao Paulo. 1989; 3(3):402-07.

9 Kabue MM, Moracha JK, Ng'ang'a PM. Malocclusion in chil-dren aged 3-6 years in Nairobi, Kenya. East Afr Med J. 1995; 72(4):210-20.

10 Otuyemi OD, Sote EO, Isiekwe MC, Jones SP, Occlusal relationships and spacing or crowding of teeth in the denti-tions of 3-4-year-old Nigerian children. Int J Paediatr Dent. 1997; 7(3):155-60.

11 Ferreira RI, Barreira AK, Soares CD, Alves AC. Prevalence of normal occlusion traits in deciduous dentition. Pesqui Odontol Bras. 2001; 15(1):23-28.

12 Yilmaz Y, Gurbuz T, Simoek S, Dalmio A. Primary canine and molar relationships in centric occlusion in three to six year-old Turkish children: a cross-sectional study. J Contemp Dent Pract. 2006; 7(3):59-66.

13 Farsi NM, Salama FS. Characteristics of primary dentition occlusion in a group of Saudi children. Int J Paediatr Dent. 1996; 6(4):253-59.

14 Abu Alhaija ES, Qudeimat MA. Occlusion and tooth/arch dimensions in the primary dentition of preschool Jordanian children. Int J Paediatr Dent. 2003 Jul; 13(4):230-39.

15 Foster TD, Hamilton MC. Occlusion in the primary dentition. Study of children at 2 and one-half to 3 years of age. Br Dent J. 1969; 126(2):76-79.

16 Bishara SE, Hoppens BJ, Jakobsen JR, Kohout FJ. Changes in the molar relationship between the deciduous and perma-nent dentitions: a longitudinal study. Am J Orthod Dentofacial Orthop. 1988; 93(1):19-28.

17 Infante PF. An epidemiological study of deciduous molar relations in preschool children. J Dent Res. 1975; 54:723-27.

18 Kerosuo H. Occlusion in the primary and early mixed denti-tions in a group of Tanzanian and Finnish children. ASDC J Dent Child. 1990; 57(4):293-98.

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ORTHODONTIC RECORD KEEPING: A STUDY

By: HAROON SHAHID QAZI - BDS, MS, MUHAMMAD SALEEM KHURRAM - BDS, MCPS, MOHTADA HASSAN - BDS, MDSC, WAHEEDULLAH KHAN - BDS, MALIK ARSHMAN KHAN - BDS, UMAR FAROOQ - BDS, MS (HI) - haroon77@gmail.com

_: ABSTRACT

The Miller-Keane Encyclopedia of Medicine, Nursing, and Allied Health, 5th Edition, describes records as "a permanent or long-lasting account of something". The importance of comprehensive orthodontic records cannot be overemphasized. Orthodontic records should not only include the initial data, but all information related to the patient's treatment, throughout treatment. Records must be permanent, lasting, durable and remain unaltered. The production, retention and archiving of clear and accurate patient records is an essential part of the orthodontists professional responsibility. The objective of this study was to determine the trend of orthodontic record keeping amongst dentists in the twin cities. Data revealed high percentage of dentists keeping good pre-treatment records, however failing to keep good progress and post treatment records.

Keywords: Documentation, archiving, long lasting records

INTRODUCTION

Record keeping is such an essential aid that its importance cannot be ignored when it comes to orth-odontics. Even diagnosis is dependent on accurate and reliable orthodontic records. The vital information required to diagnose a malocclusion and develop an orthodontic treatment plan consists of models, photo-graphs, panoramic and lateral cephalometric radio-graphs and a clinical examination.1 Ubiquitous orthodontic model has been part of orthodontics as long as we have been looking at orthodontic questions,2 plaster study casts have a long and proven history in orthodontics. They have been the "gold standard'' in orthodontics, with advantages ranging from being a routine dental technique, ease of production, inexpensiveness and ease in measurement to plaster casts being able to be mounted on an articulator for study in three-dimensions.3

A panoramic radiograph shows positioning of the teeth and their periodontal and endodontic status. Cephalometric analysis and methods of superimposi-tion are useful in monitoring the changes that are due to growth or to a combination of growth and treatment.4

The eye can grasp an idea many times faster than the ear and in general retain it far longer. Pictures are the best means of visual education and patient records should be supplemented by good photography. In addi-tion, much information that is normally lost during the course of treatment can be recorded from the mouth by photography and these pictures become valuable records.5 Orthodontic photography records the exter-nal manifestations of health, disease or deformity as related to the teeth, gums or adjacent tissues and the development of facial characteristics.6

TABLE 1: QUESTIONNAIRE

TABLE 1: QUESTIONNAIRE###

1. Do you take orthodontic records?

* Yes * No###

o Pre-treatment###

o Progress###

o Post treatment###

2. If 'YES', which ones do you take? Pre-Treatment Progress Post-Treatment

* Lateral Cephalogram

* Panorex

* Photographs

* Casts

* Others

4. To predict the growth of a patient what do you prefer?

* Serial Lateral Cephalogram * Cervical Vertebral Maturation (CVM) Method

* Hand and Wrist Radiograph###* Growth Charts

* Others

METHODOLOGY

Questionnaires were distributed to the dentists practicing orthodontics at their clinics or dental insti-tutes in the twin cities (Islamabad and Rawalpindi) and the questionnaires were collected by hand. The results were subjected to a descriptive statistical analysis with the help of SPSS 17 (Table 1).

RESULTS

The response showed that forty eight dentists were practicing orthodontics out of which 90% were docu-menting initial records, while 42% were recording progress and 60% were completing the post treatment records (Figures 1 and 2).

It was interesting to know that majority of the practicing consultants were predicting growth by cervi-cal vertebral maturation method and hand & wrist radiographs (Figure 3).

DISCUSSION

When we consider the term "records," the first thing that comes to mind is the initial gathering of information of how the patient presents, so the dentist can formulate an opinion (diagnosis).7 Although the initial records are a vital part of the patient profile, there are other issues regarding to records that all clinicians and staff must consider for diagnostic and medico-legal reasons. Initial diagnostic records should include a minimum of a patient history (medical, dental), clinical findings, TMJ examination, intra and extra oral photographs, panorex, cephalometric analysis and study models.8 The present study shows that initial records were well kept by 90% of the dentists and growth prediction was done by CVM method or hand & wrist radiograph. Persistence of hand & wrist radio-graph may be due to poor quality of lateral cephalograms.

Progress records include all events including treat-ment rendered, financial activity, correspondence, and appointment history, including missed or cancelled appointments. If a patient fails to return for treatment, a registered letter must be delivered and a copy filed in the patient record.

Frequently, when treating orthodontic patients, the treatment requires re-evaluation9 and the orth-odontist may require updated diagnostic records. The need for updated records (radiographs, models, photos) should be explained prior to the initiation of treatment. A new fee attached to "another x-ray" may lure the parent or patient to refuse the recommendation and this in turn will affect re-evaluation of the treatment and record keeping.

When the treatment is coming to an end, pre de-bond records must be considered to be satisfied with the treatment results. This may include models (check the occlusion and tooth position), photos, panorex (check the roots) and TMJ examination.10 It is a clinician's nightmare to complete a case and find out after the treatment is finished that the case could have been fine tuned. This study shows a low frequency (42%) of progress record keeping. This trend may owe to the fact that progress records may increase treatment cost, extra effort and untrained staff.

Final records are also an important part of the patient profile. The day the treatment is finished (or discontinued), models, photos, panorex, and lateral cephalogram should be taken prior to the patient leaving the department and retainers inserted. It is imperative to have a record of how the treatment was completed.11 This study shows that final record keeping is being practiced very well as far as casts and radio-graphs are concerned. However, final radiographic records have seemed not to have been very well maintained by the sample used in this study. A strong reason for this could be non compliance from patients at the end of treatment and a further increase in treatment cost. This may lure parents or patients to refuse recommendations, thus effecting record keeping.

If a patient is relocating or being referred to another clinician, the patient's records may need to be transferred. Patient information is confidential and should never leave the department without written permission.12,13 If the patient has not started treatment and the initial diagnostic records are to be transferred, a copy may be kept and the originals sent. However, if the patient is in treatment, it is advisable to send duplicate records (excluding the orthodontists notes) with a summary of the treatment rendered.

CONCLUSION

Orthodontic record keeping is an important part of any orthodontic practice. Documenting too much (ev-erything) may not be always possible. It must be remembered that if it isn't documented, it didn't hap-pen. Progress and final records are as important as the initial records. Records must be kept, maintained and archived "forever" if possible.

REFERENCES

1 Han UK, Vig KW, Weintraub JA, Vig PS, Kowalski CJ. Consistency of orthodontic treatment decisions relative to diagnostic records. Am J Orthod Dentofacial Orthop. 1991;100:212-19.

2 Isaacson RJ. Objective and Reproducible Model Assessment. The Angle Orthodontist 2010;80(3):607-08.

3 Rheude B, Sadowsky PL, Ferriera A, Jacobson A. An Evalu-ation of the Use of Digital Study Models in Orthodontic Diagnosis and Treatment Planning. The Angle Orthodontist 2005;75(3):300-04.

4 Rubin RM. Making sense of cephalometrics. The Angle Orthodontist 1997;67(2):83-85.

5 Heimlich AC. Dental Photography: Its Application to Clinical Orthodontics. The Angle Orthodontist 1954;24(2):70-78.

6 Graber TM. Patient Photography in Orthodontics. The Angle Orthodontist 1946;16(1):17-43.

7 Lawney M. For the Record. Understanding Patient Recordkeeping. N Y State Dent J 1998;64(5):34-43.

8 Collins D. What A Dentist Should Know About the Oral Health Record. Northwest Dentistry 1996; 75(1):35-39.

9 American Academy of Pediatric Dentistry. Guideline on peri-odicity of examination, preventive dental services, anticipa-tory guidance, and oral treatment for children. Pediatr Dent 2007;29:102-08.

10 American Academy of Pediatric Dentistry. Guideline on ac-quired temporomandibular disorders in infants, children, and adolescents. Pediatr Dent 2006;28:170-72.

11 American Academy of Pediatric Dentistry. Guideline on ado-lescent oral health care. Pediatr Dent 2006;28:77-84.

12 Nelson GV. Guidelines to the prevention of problems in recordkeeping. Part 1. Pediatr Dent 1989; 11(2):174-77.

13 Skifkas PM. Guarding the files. Your role in maintaining the confidentiality of patient records. JADA 1996; 127: 1248-52.
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Author:Baidas, Laila
Publication:Pakistan Oral and Dental Journal
Article Type:Report
Geographic Code:7SAUD
Date:Dec 31, 2010
Words:5712
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