British Orthodontic Conference 2007 report

In the centenary year of the British Society for the Study of Orthodontics, the theme of the annual Northcroft lecture at the British Orthodontic Conference was advances in the specialty over the last century. It was an opportunity for Professor Murray Meikle to track the major trends in orthodontics, such as extractions, bone growth, emerging techniques and multidisciplinary working.

He left the UK to become Professor of Orthodontics at the University of Otago and in the light of his personal research career, in the UK and USA, he was able to treat his audience to a historical tour of their profession which was extraordinary for its breadth and range. He dwelt extensively on craniofacial development, on which he published a book in 2002.

The starting point of his lecture was George Northcroft, the man who initiated the first meeting of the BSSO and who carried out the first known longitudinal study of facial growth by making face masks of his son William from childhood to adolescence. Northcroft is remembered to this day through the eponymous lecture at the British Orthodontic Conference, given for the first time sixty years ago, in 1937.

Professor Meikle touched briefly on the incalculable contribution of Edward Angle, Northcroft’s American contemporary, as well as his more uncertain legacy, in particular his views on extractions and bone growth. Angle’s school ridiculed claims that heredity was one of the causes of malocclusion, said Professor Meikle, believing it to be a consequence of inadequate bone growth. If patients and their parents looked the same, it was believed, it was because they had grown up in the same environment.

At that time, said Professor Meikle, Darwin’s Theory of Evolution had not been fully accepted, making such beliefs more understandable. Angle and his school also believed that bone could be grown by orthodontic means. This theory endured until a publication in 1938, the nail in the coffin of non-extraction treatment, which indicated that orthodontics was limited to the dentoalveolar process.

But thinking on craniofacial growth continued to be further refined and while it is known appliances cannot make the mandible grow appreciably, functional appliances used in the right way at the right time do seem able to modify facial growth. The difficulty is establishing exactly how since randomised controlled trials, RCTs, are still the only way to establish scientific validity.

In orthodontics, RCTs were not new, he said, but there was scepticism about some of the outcomes where the focus of the results was the average. He quoted Dick Mills: “The Mean is a lonely place to be”. The key, he said, is variation, variation, variation and this applied in the:

• timing, magnitude and duration of pubertal dentofacial growth

• difference in motivation of patients as well as operator effect

• inaccuracy of cephalometric measurements

• questionable validity of measurements used to quantify change

It is this variation which makes it so difficult to pinpoint the effect of treatment on growth.

Some of the most important innovations in orthodontics had taken place, he said in the 1960s. At the outset of that decade, orthodontists expected to have a caseload of only 50 new patients every year. The advent of direct bonding, straight wire and flexible wires had changed all that, he said. The most significant development was the use of implants as temporary anchorage devices. He concluded by looking at orthodontics and epidemiology which with genetics had assumed an important place in modern medicine.

Kissing the apex

As usual, there were several international speakers at the conference, often chosen from the elite ranks of the Angle Society of Europe. There were some excellent home-grown speakers, featuring more double acts than usual. One such double act was by Dr Ross Hobson, and Dr Francis Nohl who are part of a hypodontia clinic in Newcastle. Dr Hobson estimated that one in twenty people in the population have hypodontia and together they went on to demonstrate how effective multi-disciplinary team-working can be.

An update on endodontic development may not appear to be the most humorous of topics but in the hands of Dr John Whitworth, it was the comical highlight of the British Orthodontic Conference. Videos were shown to demonstrate the optimum preparation of the root canal.

He described using a rotary handpiece to reach the root tip, or, as he said with feeling, “Kiss the apex”, and then went on to deliver a “mwah”, to the great amusement of an audience already in the palm of his hand. For those who have not done any endodontics for some while, namely the majority of the audience, his talk provided highly valuable learning points, enhanced by his passion for the specialty.

Vertical and soft tissue considerations in functional appliance treatment were elaborated on by Dr John Bennett, one of the giants of British orthodontics. The cases he presented illustrated the advantages of functional appliances, which he shares with patients, namely to improve facial harmony, to better the occlusion, and…..improve the airway, thus reducing the likelihood of sleep apnoea.

He stressed the importance of appliance selection in high and low angle cases and dismissed the “one size fits all” approach to functionals. His handling of patients is geared to maintaining motivation throughout treatment. This is achieved by making and placing a wax bite to demonstrate to parent and child the difference that treatment will make and spending enough time at appointments.

Dr Robert Kirschen’s talk was Bonded Retention for Dummies. Dr Kirschen started by paying tribute to John Bennett who he said had inspired him to move into private practice more than 20 years ago. He went on to look at research into retention failure rates, some of which was worryingly high.

It concerned him was that these findings would reinforce the view that bonded retainers did not work and deter colleagues from attempting to use it for their patients. His impressively low failure rate ensured close attention was paid to his technique and choice of materials. He spoke about the big and the little picture with regard to relapse and repeated the orthodontic epithet: Retention is not a problem in orthodontics, it is THE problem.

The topic of the talk by John Tiernan, Deputy Director of Dental Protection Ltd was the pitfalls of modern day orthodontics and he focused on complaints and how to minimise them. He explained that legal proceedings were often triggered by an emotional response to the clinician or his team.

There was generally a precipitative factor, when something went wrong, but this was usually preceded by a predisposing factor, such as rudeness of staff or poor communication, which made the patient more inclined to complain or to sue. Patients who love their clinician, on the other hand, are more likely to overlook or forgive a mistake or oversight.

Complaints about orthodontic treatment tend to be made at a much later date than general dental complaints, he said, making it all the more important to keep good records of what is said. The best person to make a record or diary of the patient consent process was the dental nurse. This should then be scanned and kept electronically to provide proof it was a contemporaneous record.

He provided examples of orthodontic complaints settled recently which ranged from £101,000 at the top end to £29,000 at the lower end, paid out for a devitalised incisor. Only three per cent of the complaints made worldwide about Dental Protection members related to orthodontics, said Dr Tiernan.

Practice development session
Delegates at the British Orthodontic Conference were prepared for the new world of local commissioning at the Practice Development Session organised by the Orthodontic Specialists Group, on the first morning of the conference. Among the changes on the horizon is a patient questionnaire which the Business Services Authority is going to be sending to patients, checking on the orthodontic treatment they received and their views on a variety of aspects of the serviced they received

Brian Kelly, the senior orthodontic advisor for the NHS Business Service Authority said that the questionnaires would be dropping on the doormats of patients in the coming three month period. There were 15,000 case starts every month in England and Wales, he said and 25 per cent of patients would be asked to fill in the questionnaire.

Dr Kelly, a specialist practitioner from Coventry, described the activity monitoring which was being carried out by the BSA, with a special focus on identification of statistical outliers. Also to come in the future are mid-case record card checks. PCTS were being asked to look at cases which had begun prior to the new contract and where no information on discontinuation has been received.

He also described a traffic light style system which would allow BSA to alert PCTs to investigate any practitioners whose profiles indicated a red light with an amber light highlighting those in need of a discussion about their schedules.

The panel of four speakers also included, Sue Gregory, Consultant in Dental Public Health in Bedfordshire and for two Primary Care Trusts in Hertfordshire. She suggested that cases normally undertaken in secondary care would increasingly take place in primary care. As an example, there was a nine surgery poly-clinic in her area, she said, which was highly suitable for training specialists.

She discussed the changes that commissioning would bring and described the work of a new oral health commissioning group which had been set up in her area. She added there would be no national tariff but more market testing and bench-marking to ensure value for money. She said an independent organisation was now working with the Department of Health on collection of data and how to improve it.

In order to reassure her audience, she quoted the new Health Minister responsible for dentistry, Ann Keen, who earlier in the week said the legal and moral duty to provide NHS services would remain in perpetuity. She had also said that 2009 – the start of local commissioning – would not be another 2006. In future, she said, provision would be based on local needs rather than on best guesses or what happened elsewhere. She also predicted a growth in corporates.

Other speakers in this session were Richard Jones, the chairman of the British Orthodontic Society’s Orthodontic Practice Committee and Dr Jo Clarke, a Consultant Orthodontist in Chichester in Sussex.

Turn-out for the session, was excellent, reflecting the new climate in which orthodontists are now working, and included strong representation from COG. There is no doubt that orthodontists have shared

Editor: Caroline Holland
Conference reporters: Anjli Patel, Jamie Gwilliam, Cleo Darwish, Nozha Khader and Marwa Al-Halawani