tjaoftai JcmmmlcfOnJudaula 11 (1989) 309-320 C 19*9 European Orthodontic Society

The development of an index of orthodontic treatment

priority
Peter H. Brook* and William C. S h a w "

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* University College Hospital, London
** University Dental Hospital of Manchester, England

SUMMARY The aim of this study was to develop a valid and reproducible index of orthodontic
treatment priority.
After reviewing the available literature, it was felt that this could be best achieved by using two
separate components to record firstly the dental health and functional indications for treatment,
and secondly the aesthetic impairment caused by the malocclusion.
A modification of the index used by the Swedish Dental Health Board was used to record the
need for orthodontic treatment on dental health and functional grounds. This index was modified
by defining five grades, with precise dividing lines between each grade.
An illustrated 10-point scale was used to assess independently the aesthetic treatment need of
the patients. This scale was constructed using dental photographs of 12-year-olds collected
during a large multi-disciplinary survey. Six non-dental judges rated these photographs on a
visual analogue scale, and at equal intervals along the judged range, representative photographs
were chosen.
To test the index in use, two sample populations were defined; a group of patients referred for
treatment, and a random sample of 11 -12-year-old schoolchildren. Both samples were examined
using the index and satisfactory levels of intra- and inter-examiner agreement were obtained.

Introduction of the previously held views on the benefits of

Whilst many indices exist to record malocclu-
sion, it is important to distinguish those that
classify malocclusions into types (Angle, 1899)
and those that record prevalence in epidemi-
ological studies (Bjork et al., 1964), from those
indices that attempt to record treatment need or
priority. Furthermore, indices used to record
treatment success and treatment difficulty will
have differing requirements.
Many indices have been developed with the
intention of categorizing malocclusions into var-
ious groups, according to the urgency and need
for treatment (Summers, 1971; Salzmann, 1968;
Linder-Aronson, 1974; Lundstrdm, 1977; Gra-
inger, 1967; Draker, 1960). Individuals with
greatest treatment need can then be assigned
priority when orthodontic resources are limited,
and when the availability of treatment is
unevenly spread. Similarly, individuals with little
need for treatment can be safeguarded from the
potential risks of treatment (Shaw, 1988).
Recent research has called into question many
orthodontic treatment (Shaw et al., 1980). There
may be small effects on the susceptibility to
temporomandibular dysfunction (Roth, 1973;
Mohlin and Thilander, 1984) and periodontal
disease (Horupe/ al., 1987;Sandali, 1973;Davies
etal, 1988; Addy etal, 1988). However, so many
studies have been undertaken on these subjects,
with differing conclusions, and often only weak
statistical associations, that it is difficult to
believe that the effect, with a small number of
specific exceptions, can be anything but minor.
There will be a reduced incidence of trauma to
incisors where treatment reduces their promi-
nence. However, treatment needs to be carried
out early (before the child is 10-years-old) if the
peak incidence of trauma is to be avoided
(Jarvinen, 1979). The avoidance of tooth impac-
tion is also desirable.
The main benefit to the patient of orthodontic
treatment may be in improved aesthetics and
social-psychological well-being, and additionally
the effect this may have on attitudes to dental
health. This has important implications in the
310
construction of any treatment priority index.
Such an index must involve an aesthetic assess-
ment, and allow appropriate weighting for this
component.
Subjects and materials
The following criteria were considered to be
important in the development of a new index of
orthodontic treatment need.
1. Separate components to record:
(a) Functional and dental health indications
for treatment.
(b) Aesthetic impairment.
2. For the functional and dental health compo-
nent, each occlusal trait thought to contribute
to the longevity and satisfactory functioning
of the dentition, needs to be defined, and
easily measurable cut-off points between each
grading need to be established.
In view of the uncertainty of the relative contri-
bution that each occlusal trait makes to the
longevity and satisfactory functioning of the
dentition and indeed the doubt surrounding the
importance of aesthetics in the provision of
orthodontic care, the indices needed to be suffi-
ciently flexible to allow for adjustment of cut-off
points and relativities between the categories, as
the results from adequate longitudinal research
become available.
Development of the dental health component
With these criteria in mind, the index of treat-
ment priority used by the Swedish Dental Board
(Linder-Aronson, 1974) was used as the basis for
grading the functional and dental health indica-
tions for treatment. There arefivegrades, grade 1
representing little or no need for treatment and
grade 5 representing great need of treatment
(Table 1). An attempt was made to try to
establish from the literature meaningful values
for cut-off points between grades for each occlu-
sal trait that represents a quantifiable threat to
the dentition.
Most of the traits are recorded using a milli-
metre rule, modified to incorporate a device for
angular measurements. Crowding was recorded
by measuring the largest displacement between
teeth in the arches, using a modified version of
the index described by Lau et al. (1984).
In use, only the highest scoring trait need be
recorded, as this determines the grading of the
patient.
PETER H. BROOK AND WILLIAM C. SHAW
The aesthetic component
The second part of the overall assessment of
treatment priority, was to record the aesthetic
impairment contributed by the malocclusion.
For this component the SCAN Index (Standar-
dized Continuum of Aesthetic Need) was utilized
(Evans and Shaw, 1987).
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This scale was constructed using dental photo-
graphs of 1000 12-year-olds collected during a
large multi-disciplinary survey. Six non-dental
judges rated these photographs on a visual
analogue scale, and at equal intervals along the
judged range, representative photographs were
chosen giving a 10-point scale from 0.5 (attrac-
tive dental appearance) to 5.0 (unattractive den-
tal appearance) (Fig. 1).
Testing the index
Two-hundred and twenty-two patients referred
to a regional orthodontic centre for advice or
treatment were examined under ideal lighting
conditions with radiographs available. Both
components of the index were applied and the
patients were also asked to give their own rating
on the aesthetic scale.
Intra-examiner error was estimated by the same
examiner seeing 67 of these patients on two
occasions, at least one week apart, without
reference to notes. A second examiner assessed
72 of the patients independently of the first
examiner to estimate inter-examiner error. To
simulate the use of the indices in a screening
programme, 333, 11-12-year-old school children
were examined. A cross section of schools
attended by children from a broad range of social
backgrounds were visited, and all available chil-
dren in thefirstyear of secondary education were
examined. Each child was examined in the school
medical room using an angle-poise lamp for
lighting, a simple millimeter rule and a dental
mirror. Again, both components of the index
were applied, and the self rating recorded on the
SCAN scale. In addition a dental surgery assist-
ant recorded her rating on the SCAN scale.
Forty-six children were chosen at random for re-
examination.
Amongst the school sample 58 (17.4 per cent)
of the children were undergoing, or had com-
pleted orthodontic treatment. The orthodontist
involved in the treatment of each of these
children was contacted so that details of the
original malocclusion and information from the
ORTHODONTIC TREATMENT PRIORITY 311
Table 1 Index of orthodontic treatment need dental health component: for use on patients.

Grade 5Very great

Defects of deft lip and/or palate.
Increased overjet greater than 9 mm.
Reverse overjet greater than 3.5 mm with reported masticatory or speech difficulties.
Impeded eruption of teeth (with the exception of third molars) due to crowding, displacement, the presence of supernumerary
teeth, retained deciduous teeth and any other pathological cause.
Extensive hypodontia with restorative implications (more than one tooth missing in any quadrant) requiring pre-restorative

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orthodontics.
Grade 4Great
Increased overjet greater than 6 mm but less than or equal to 9 mm.
Reverse overjet greater than 3.5 mm with no reported masticatory or speech difficulties.
Reverse overjet greater than 1 mm but less than or equal to 3.5 mm with reported masticatory or speech difficulties.
Anterior or posterior CTOssbites with greater than 2 mm displacement between retruded contact position and intercuspal
position.
Posterior lingual crossbites with no occlusal contact in one or both buccal segments.
Servere displacement of teeth greater than 4 mm.
Extreme lateral or anterior open bite greater than 4 mm.
Increased and complete overbite causing notable indentations on the palate or labial gingivae.
Patient referred by colleague for collaborative care e.g. periodontal, restorative or TMJ considerations.
Less extensive hypodontia requiring pre-restorative orthodontics or orthodontic space closure to obviate the need for a
prosthesis (not more than 1 tooth missing in any quadrant).
Grade 3Moderate
Increased overjet greater than 3.5 mm but less than or equal to 6 mm with incompetent lips at rest.
Reverse overjet greater than 1 mm but less than or equal to 3.5 mm.
Increased and complete overbite with gingival contact but without indentations or signs of trauma.
Anterior or posterior crossbite with less than or equal to 2 mm but greater than 1 mm displacement between retruded contact
position and intercuspal position.
Moderate lateral or anterior open bite greater than 2 mm but less than or equal to 4 mm.
Moderate displacement of teeth greater than 2 mm but less than or equal to 4 mm.
Grade 2Little
Increased overjet greater than 3.5 mm but less than or equal to 6 mm with lips competent at rest.
Reverse overjet greater than 0 mm but less than or equal to 1 mm.
Increased overbite greater than 3.5 mm with no gingival contact.
Anterior or posterior crossbite with less than or equal to 1 mm displacement between retruded contact position and intercuspal
position.
Small lateral or anterior open bites greater than 1 mm but less than or equal to 2 mm.
Pre-normal or post-normal occlusions with no other anomalies.
Mild displacement of teeth greater than 1 mm but less than or equal to 2 mm.
Grade 1None
Other variations in occlusion including displacement less than or equal to 1 mm.

study models could be used in place of the
recordings taken at the school visits. In practice,
as many of the children were only just commenc-
ing treatment, the gradings were little changed.
Results
Reproducibility of the index
Dental health component
Intra-examiner agreement ranged from a Kappa
value of 0.837 for the referred population seen
under ideal conditions, to 0.754 for the non-
referred population. In total there were 14 errors
out of 118 re-tests and in all cases the disagree-
ment was only by one grade. Guidelines for the
interpretation of the Kappa statistic (Landis and
Koch, 1977) are shown in Table 2.
Inter-examiner agreement ranged from 0.731-
0.797. In total there were 21 out of 154 measure-
ments that were not agreed. There were only 2
cases where the error was by more than one
grade.
SCAN component
For the referred sample there were three raters;
the patient and the two examiners. This gave two
patient ratings (PI and P2), two ratings by
81:4 PETER H. BROOK AND WILLIAM C. SHAW

05

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35

1-5

45

25
Figure 1 The SCAN Scale. Originally presented in colour in a horizontal arrangement. 0.5 extreme left. 5 extreme right.

Table 2 Guidelines for the interpretation of Kappa. Table 3 Examiner variability. Pearson's correlation
coefficients for SCAN.
Kappa statistic Strength of agreement
Referred Population
<0.00 Poor
0.00-0.20 Slight PB2 PI P2 WCS
0.21-0.40 Fair
0.41-0.60 Moderate PB1 0.87 0.50 0.36 0.71
0.61-0.80 Substantial (72) (82) (72) (82)
0.81-1.00 Almost perfect
PB2 0.45 0.40 0.73
(72) (72) (72)
PI 0.67 0.37
(72) (82)
examiner 1 (PB1 and PB2), and one rating by P2 0.29
examiner 2 (WCS). The examiner reproducibi- (72)
lity, and the comparability of patient and exa-
miner ratings, were investigated using Pearson's
correlation coefficient. The results are listed in tists were quite high, they were poorer than those
Table 3 with the number of repeat examinations obtained by Evans and Shaw (1987), where self-
in parenthesis. retaining lip retractors were used during the
Whilst the correlations between the orthodon- orthodontists' and the patients' assessments. For
ORTHODONTIC TREATMENT PRIORITY 313

this reason, self-retaining cheek retractors were in Table 5, and Figs. 2 and 3. The SCAN Index
used routinely for the examination of the non- scores are illustrated in Table 6, and Figs. 4 and
referred sample. 5.
In the school survey, 46 subjects were rated
twice by the orthodontist (PB) on the SCAN
Discussion
scale. Additionally, there was a rating by the
dental surgery assistant on two occasions (DSA1 Reproducibility

and DSA2), and two subject ratings (SI and S2).
Again, these relationships were examined using
Pearson's correlation coefficient (Table 4).
On this occasion intra-examiner agreement for
the orthodontist (PB) was better. The DSA's
reproducibility was less good. There was how-
ever, superior inter-examiner agreement on this
occasion. There was also better correlation
between the subjects' and the professionals'
ratings.
General features of the referred and non-referred
populations
The numbers of patients falling into each Dental
Health Index grade for each group are illustrated
Table 4 Examiner variability. Pearson's correlation
coefficients for SCAN.
School Population
DSA2 SI S2 PB1
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Dental health component
In general, the reproducibility of this index was
very good. The same grade was re-chosen 86.4
per cent of the time with different examiners, and
in 93 per cent of cases for the same examiner
under the more ideal clinic setting (the referred
population).
The common traits causing disagreement, in
descending order of frequency were; crowding,
increased overjet, crossbites and overbites.
Crowding represents a problem in recording
when the patient is in the mixed dentition.
Further refinement of the index in terms of the
mixed dentition analysis of crowding, may lead
to an improvement in reproducibility.
Evidently, the less than ideal conditions of the
school examination resulted in poorer reproduci-
bility. Should reproducibility levels similar to
that of the referred population be required, then
better lighting, better patient seating facilities
PB2 and a more relaxed work rate would be required.

DSA1 0.78 0.66 0.70 0.80 0.81 SCAN component

(46) (46) (46) (46) (46) Whilst the correlation coefficients for the SCAN
DSA2 0.61 0.69 0.85 0.88 ratings were reasonably high for the school
(46) (46) (46) (46)
survey, they were less satisfactory for the referred
SI 0.78 0.64 0.61
(46) (46) (46)
population. It was felt that this may have been
S2 0.68 0.69
due to the omission of the self-retaining lip
(46) (46) retractors for this sample.
PB1 0.95 During the original development of the index,
(46) both front and side views of the dentition were
available. This enabled conditions such as large
overjets to be more readily assessed. During the
surveys, it was noted that the areas around 1.5
Table 5 Distribution of Dental Health grades. and 4.0 on several raters graphs, showed slight
inconsistencies. An inspection of the index
Dental Referred population School population
health
demonstrates the difficulties that may be leading
grade Numbers Percentage Numbers Percentage to these effects. Both the representations of 2.0
and 4.5 show increased overjets, that a lay person
Grade 1 1 0.5 24 7.2 in the absence of a side view, may not find too
Grade2 11 5.4 93 27.9 displeasing.
Grade 3 40 19.7 107 32.1
Grade 4 112 55.2 92 27.6 So, in summary, incorporation of side views
Grade 5 39 19.2 17 5.1 may assist in identifying large overjets. Some
Total 203 100.0 333 100.0 guidelines for assessing the relative attractiveness
of features not depicted on the scale, may also be
314
REFERRED POPULATION DHI
1 2
DENTAL HEALTH INDEX SCORE
Figure 2 Distribution of ratings for the Dental Health Index obtained from examination of 222 patients referred to a regional
orthodontic centre.
desirable. Self-retaining cheek retractors are a
useful aid to recording dental aesthetics.
The referred sample
As expected, the referred sample showed a large
proportion of patients scoring in the higher
grades of the Dental Health Index, with all but 6
per cent in the highest three grades. The ortho-
dontists' SCAN ratings showed a similar shift to
the unattractive side. The patient ratings showed
this effect to a much smaller extent.
The school population
There was a much more even spread of patients
amongst the grades of the Dental Health Index
for this population, with approximately one
third of the subjects in grade 3, and one third
either side of this. The professional ratings using
PETER H. BROOK AND WILLIAM C. SHAW
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3 4 5
the SCAN Index, showded a distribution skewed
towards the attractive end of the scale. The
patient ratings are skewed even further towards
the attractive end of the scale, i.e. there was a
tendency for subjects to overrate their dental
attractiveness.
Comparison of the two samples
From an overview of the data recorded from the
samples, it appears quite obvious that there are
significant differences between them. Indeed the
median test and the /-test demonstrate this
readily for the Dental Health component and the
SCAN component respectively (p< 0.0001).
However, the findings from the two surveys
are not directly comparable. Firstly, the referred
sample had a wide age spread, and secondly,
when applying the Dental Health component to
ORTHODONTIC TREATMENT PRIORITY 315

SCHOOL POPULATION DHI

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1 2 3 4 5
DENTAL HEALTH INDEX SCORE
Figure 3 Distribution of ratings for the Dental Health Index obtained from examination of 333 unselected schoolchildren.

the referred population, the examiners had Table 6 Distribution of SCAN ratings (Orthodontist
access to radiographs. For the school sample, it score).
was necessary to set criteria for such parameters
as unerupted or missing teeth, i.e. except for Referred Population School 1Population
incisors and first molars, all teeth were assumed SCAN
to be present, at age 11-12 years, premolars and rating Numbers Percentage Numbers Percentage
canines were assumed to be unerupted but not
0.5 0 0.0 16 4.8
impacted, missing upper lateral incisors and 1.0 2 1.0 54 16.2
lower incisors were assumed to be developmen- 1.5 19 9.4 65 19.5
tally absent whereas missing upper central inci- 2.0 17 8.4 59 17.7
sors and first molars were assumed to have been 2.5 28 13.8 62 18.6
extracted. 3.0 33 16.3 33 9.9
3.5 39 19.2 26 7.8
In an attempt to overcome this, a sub-group of 4.0 48 23.6 12 3.6
25 from the referred sample, with a similar age 4.5 8 3.9 5 1.5
range to the school sample was selected. Any 5.0 8 3.9 1 0.3
conditions that would have required radiographs Total 202 100.0 333 100.0
to confirm the diagnosis, were regraded using the
 316 PETER H. BROOK AND WILLIAM C. SHAW

REFERRED POPULATION SCAN

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4 5 6 7 8
SCAN RATING
Figure 4 Distribution ot raungs for the SCAN index obtained from examination of 222 patients referred to a regional
orthodontic centre.

criteria set for the population seen without acceptable as it has been shown that most of the
radiographs. traits can be recorded with a high degree of
It was still evident that the samples were drawn
precision (Helm et al., 1975; Helm, 1977) with up
from different populations (Mest p< 0.001 for to 80 per cent agreement. However in their pure
the SCAN ratings; median test p< 0.001 for the form they do not record treatment priority.
Dental Health ratings). These tests seemingly The allocation of weighting factors to traits
validate the index, at least in terms of the can give an overall figure that is intended to
priorities of patients or dentists in bringing about
represent a score of severity, and thus treatment
referral to an orthodontist. priority. Several indices of this type have been
developed (Summers, 1971; Draker, 1960; Gra-
Comparison with previous methods of recording inger, 1967). Correlation coefficients for exa-
treatment priority miner agreement for such indices have ranged
Angle's classification (Angle, 1899) has been from a Spearman correlation coefficient of 0.903
shown to have poor reproducibility (Gravely and (Summers, 1971) to as low as 0.34 (Albino et al.,
Johnson, 1974) and has no usefulness in record- 1978) in a community screening setting. The
ing treatment priority. For epidemiological use, validity of such indices relies on acceptance of the
the registration techniques described by Bjork et authors' weightings.
al. (1964) and Baume et al. (1973) may be quite Indices based upon the classification of mor-
ORTHODONTIC TREATMENT PRIORITY 317

SCHOOL POPULATION SCAN

30

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25-

P 19.5
E 20 - 18.6
R 17.7
C
E 15 -
N
T
A 9.9
G 10-
E 7.8

5 - 3.6
1.5
0.3

1 2 3 4 5 6 7 8 10
SCAN RATING
Figure 5 Distribution of ratings for the SCAN index obtained from examination of 333 unselected schoolchildren.

phological traits rely on the subjective opinion of
an experienced judge to define the dividing lines
between each trait (Linder-Aronson, 1974;
Lundstrom, 1977; Malmgren, 1980). Used as
such, the percentage concordance ranges from
55.9 to 74.6 per cent (Malmgren, 1980).
Subjective clinical opinion alone has agree-
ment of about 80 per cent in most studies
(Bowden and Davies, 1975; Helm et ai, 1975)
but the validity of such judgements depends
upon the examiners' knowledge of the harmful
effects of malocclusion. In addition, inexper-
ienced examiners will find it difficult to apply
such techniques.
The orthodontic index of treatment need"
described in this report has examiner agreement
levels that compare well with any of those
previously described (80.5-93 per cent). As its
development was based upon a full analysis of
the available literature (Brook, 1987) and the
experience gained from a longitudinal survey
(Shaw et ai, 1986), it is not felt that its validity
can be inferior to that of other indices. The
inclusion of a separate index to record aesthetic
impairment removes the most subjective element
from indices of this kind. Good levels of agree-
ment for this component have been demon-
strated (Pearson's correlation coefficient values
from 0.71-0.95).
Some support for the validity of the index
comes from the observation that fewer subjects
in the lower grades were referred for orthodontic
advice. The extent to which it represents com-
mon professional opinion is presently being
evaluated. However, true validity (i.e. that the
index measures what it purports to measure)
318 PETER H. BROOK AND WILLIAM C. SHAW

Table 7 Interrelationship between the SCAN and Dental Health Index scores.

(Cumulative Percentages)

DHI SCAN Score

Grade 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 4.5 5.0 Total

1 2.1 5.4 6.3 6.6 7.2 7.2 7.2 7.2 7.2 7.2 7.2
2 4.2 15.6 25.8 31.8 34.8 35.1 35.1 35.1 35.1 35.1 35.1

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3 4.5 19.5 37.2 51.3 60.9 64.5 65.7 67.2 67.2 67.2 67.2
4 4.8 20.4 39.6 57.3 75.3 84.9 91.5 93.9 94.8 94.8 94.8
5 4.8 21.0 40.5 58.5 76.8 86.7 94.5 98.2 99.7 100.0 100.0
Total 4.8 21.0 40.5 58.5 76.8 86.7 94.5 98.2 99.7 100.0 100.0

must await the compilation of a greater body of tions could produce a similar percentage. An
knowledge than that which is currently available. alternative method would be to combine the
It may accurately reflect contemporary profes- scores from the two components to give an
sional opinion, but this may be erroneous. overall score, then define limits based on this
figure.
Epidemiological uses for the index Eventual definitions of cut-offs must reflect the
During testing of the index on the school sample, setting in which treatment would be provided
it was felt that it represented a simple, quick and and include a consideration of the success rate of
reasonably reproducible method of recording the treatment which would be available, the
orthodontic treatment need. As all the traits are iatrogenic risks, and the cost (Shaw, 1987).
simple to record, it may be possible for less highly
trained personnel to apply the index, following
suitable training and calibration. Conclusions
An index with two components has been devel-
Further development of the index oped to record orthodontic treatment priority.
As developed so far, the index records the dental The first of these components records need for
health need for treatment, and the aesthetic treatment on dental health and functional
impairment, and by implication the social- grounds. The second component records the
pschological need for treatment. As yet, no aesthetic impairment, and by implication, the
attempt has been made to combine these into an justification for treatment on social-psychologi-
overall assessment of treatment need, or to define cal grounds.
scores below which treatment should be with- The indices were tested on a sample of patients
held. referred for orthodontic treatment and advice,
To assist discussion in this area, a table and on a random selection of 11-12-year-old
showing the cumulative percentages of patients school children. It was easy and quick to use and
having varying combinations of the Dental had acceptable reproducibility. True validation
Health grades, and the SCAN ratings has been of such an index must await the emergence of
constructed from the non-referred sample (Table further research data on the effects of malocclu-
7). sion, but the present index can be adaptable to
Many authors quote figures of around 50 per new information. Work is currently in progress
cent for the percentage of children who would to gauge the extent to which the index reflects
benefit from orthodontic treatment (Gardiner, common professional opinion.
1956; Haynes, 1982; Foster and Walpole Day, Defining specific ranges within which patients
1973). From Table 7, it can be seen that this should, or should not be offered treatment has
number would be obtained if patients scoring 'not been attempted but a mathematical model
grade 3 or less on the Dental Health Index and has been suggested that can define combinations
2.0 or less on the SCAN scale were excluded (51.3 of the gradings that will encompass varying
per cent), leaving 48.7 per cent. Other combina- proportions of a target population.
ORTHODONTIC TREATMENT PRIORITY
Acknowledgements
The authors would like to thank Mr G. O. Taylor
and his staff for providing access and assistance
for the school visits, Mrs H. Worthington and
Mrs C. Mitropoulos for advice with the study
design and statistics, Mr J. Sinclair for computa-
tional assistance and Mrs C. Corkill for acting as
a scribe. The study was supported in part by a
grant from the DHSS and BLG.
Address for correspondence
Professor W C Shaw
Department of Orthodontics
University Dental Hospital of Manchester
and Turner Dental School
Higher Cambridge Street
Manchester M15 6FH
England
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