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O R I G I N A L A R T I C L E

E q u i t y a n d o r t h o d on t i c t r ea tm en t : A st u d y am o n ga d o l esc en t s i n N o r t h e r n I r e l a n d

B o r g h i l d B r e i s t e in , M P h i l, B D S , D O r t h R C S , a a n dD o n a l d J . B u r d e n , P h D , M S c , B D S , F D S R C P S , F F D R C S l , M O r t h R C S bBelfast, Northern IrelandTh is ep idem io log ica l s tudy inve s t iga ted the reasons why ch i ld ren in Nor thern I re land wh o need o r tho-don t ic t r ea tm ent do no t rece ive trea tme nt even when i t is p rov ided f ree by the s ta te . A to ta l o f 158415- and 16-year -o lds were examined in 23 h igh schoo ls w i th t he Index o f O r thodont ic T rea tmentNeed. The charac te r is t ics o f t he ado lescen ts who had rece ived o r thodont ic t r ea tment werecom pared wi th t hose w ho had a de f in i te need fo r t r ea tme nt and ye t d id no t rece ive t rea tmen t o radv ice . One in 10 o f t he ado lescen ts examined had an unmet need fo r o r thodont ic t r ea tment .Log is t ic regress ion ana lys is was u sed to assess the in f luence o f 11 var iab les inc lud ingsoc ioeconomic s ta tus , re l ig ion , and s tandard o f den ta l hea l t h on the up take o f o r thodont ic care .Th is ana lys is revea led tha t t he on ly s ign i f i can t p red ic to rs o f whethe r an ado lescen t rece ived o r tho-don t ic t r ea tment was the den ta l a t t endance pa t te rn o f t he ado lescen t , t he ado lescen t ' s den ta lhea l t h , and the den ta l a t t endance pa t te rn o f t he ado lescen t ' s mother . Those ado lescen ts who hadgood den ta l hea l t h , wh o regu la r ly a t t ended a den t is t , and whos e m other regu la r ly a t t ended adent is t were m ore l i ke ly t o rece ive o r thodont ic t r ea tm ent . (Am J Or thod D ento fac ia l O r thop 1998;113:408-13. )

I n m a n y c o u n t r ie s ac c e ss t o h e a l t h c a r e h a sb e c o m e a n i m p o r t a n t s o c i a l a n d p o l i t i c a l i s s u e . A s ar e s u l t , c o n s i d e r a b l e r e s e a r c h i s n o w f o c u s e d o n w h a th a s b e e n t e r m e d i n e q u a l i t y in h e a l t h c a r e . 1 E q u a l i t y i nt h e d e l i v e r y o f o r t h o d o n t i c t r e a t m e n t h a s r a r e l y b e e ns t u d i e d . D i f f e r e n t c o u n t r i e s h a v e a d o p t e d v a r y i n gm e t h o d s o f f u n d i n g o r t h o d o n t i c t r e a t m e n t f o r c h il -d r e n . I n c o u n t r i es t h a t e m b r a c e t h e p r i n c ip l e o f p u b -l ic ly f u n d e d o r t h o d o n t i c c a r e f o r a ll c h i l d r e n i n n e e d , i ti s e s p e c i a ll y i m p o r t a n t t o e n s u r e t h a t a l l s e c t io n s o fs o c i e t y h a v e e q u a l a c c e s s to t h i s e x p e n s i v e r e s o u r c e .W i t h i n t h e U n i t e d K i n g d o m ' s N a t i o n a l H e a l t h S e r -v i c e , o r t h o d o n t i c c a r e i s p r o v i d e d f r e e f o r a l l p e r s o n sy o u n g e r t h a n 1 8 y e a r s o f a g e w h o n e e d t r e a t m e n t .D e s p i t e t h is u n i v e r s a l e n t i t l e m e n t t o o r t h o d o n t i c t r e a t -m e n t , a r e c e n t n a t i o n a l d e n t a l s u r v e y c a r r i e d o u t i n t h eU n i t e d K i n g d o m r e v e a l e d t h a t 1 5 % o f 1 5 - y e a r - o l d sw e r e i n d e f i n i t e n e e d o f o r t h o d o n t i c t r e a t m e n t a n dh a d n o t r e c e i v e d t r e a tm e n t . 2 I n t h e U n i t e d K i n g d o mt h i s i s a n a g e w h e n m o s t c h i l d r e n w h o a r e g o i n g t o

From the School of Clinical Dentistry, The Queen's University of Belfast.Supported by the Department of Health and Social Services for NorthernIreland."Orthodontic Division.bOrthodontic Division.Reprint requests to: Dr. Donald J. Burden, Orthodontic Division, Schoolof Clinical Dentistry, The Queen's University of Belfast, Royal VictoriaHospital, Grosvenor Rd., Belfast BT12 6BP, Northern Ireland, UK.Copyright 9 1998 by the American Association of Orthodontists.0889-5406/98/$5.00 + 0 8/1/822304 0 8

r e c e i v e o r t h o d o n t i c c a r e h a v e a l r e a d y r e c e i v e d t h e i rt r e a t m e n t ?T h e e p i d e m i o l o g i c a l s t u d y r e p o r t e d i n t h i s a r t i c l ei n v e st ig a t e d t h e r e a s o n s w h y c h i l d r en w h o n e e d o r t h o -d o n t i c tr e a t m e n t d o n o t r e c e i v e t r e a t m e n t e v e n w h e nt h e t r e a t m e n t i s p r o v i d e d f r e e b y th e s ta te . T h e s t u d ye x p l o r e d w h e t h e r a n y i n e q u a l i ty e x i st e d in t h e d e l i v e r yo f o r t h o d o n t i c c a r e in N o r t h e r n I r e la n d . N o r t h e r nI r e l a n d i s th e s m a ll e st c o u n t r y in t h e U n i t e d K i n g d o mw i t h a p o p u l a t i o n o f 1 . 6 m i l l i o n , a c c o u n t i n g f o r 2 . 8 %o f t h e U . K . t o t a l p o p u l a t i o n . I t i s a l so a d e e p l y d i v i d e ds o c i e ty ; d iv i si o n s e x is t b e t w e e n t h e P r o t e s t a n t C a t h o l i cc o m m u n i t i e s th a t a r e r o o t e d i n se v e r al h u n d r e d y e a r s

o f h i s to r y .M E T H O D A N D M A T E R I A L ST h e S a m p l e

A sample o f 15- and 16-year-old adolescents in N orth ernIreland was selected f or examination with a rand om clustertechnique. All the 233 high schools in Nor ther n Ireland werestratified according to their socioeconomic profile and thelocal availability of o rthod ontic care. P recise details of thechildren's socioeconomic status were not initially available,so the socioeconomic profile of each school was determ inedfrom th e pro port ion o f children a t tending the school whoreceived free school meals . In the Uni ted Kingdom freeschool meals are available to children whose parents areunemployed or who are on low income. These data wereused to classify each school as having an above average,average, or below average socioeconomic profile. Details o f

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the number of orthodontists and their practice location(s)were u sed to classify he local availabili ty of ortho don tic carefor each school. This availabili ty was calculated on a ses-sional basis pe r week f or ev ery 100 adolescents 15- to16-years-old in the local population. Lo cal availability wasclassif ied as good i f there were gre ater than 1.5 or thod ont ictreatment sessions per week per 100 15- and 16-year-olds.Orthodontic treatment availabili tywas classified as average iffewer than 1.5 but m ore th an 0.5 sessions were available eachweek, and poor i f fewer than 0.5 t reatment sessions wereavailable. Twenty-four schools were th en ra ndo mly selectedfrom these n ine st ra ta proport ional to the nu mb er of f i fth-form ers (15- to 16-year-olds) in eac h subgroup.T h e S u r v e y

T h e h e a d t e a c h e r s o f e a c h s e le c t e d s c h o o l w e r ec o n t a c t e d , t h e a i m s a n d c o n d u c t o f t h e s t u d y w e r ee x p l a i n e d , a n d p e r m i s s i o n t o v i s i t t h e i r s c h o o l w a ss o u g h t . P a r e n t s o r g u a r d i a n s o f th e f i f t h - f o r m p u p i l si n e a c h p a r t i c i p a t i n g s c h o o l w e r e c o n t a c t e d i n w r i t-i ng . T h e y w e r e i n f o r m e d o f th e p r o p o s e d s u r v e y a n dg i v e n t h e o p p o r t u n i t y t o w i t h d r a w t h e i r c h i ld i f t h e yd e s i re d . T h e w r i t t e n c o n s e n t o f e a c h a d o l e s c e n t w a sa l s o o b t a i n e d b e f o r e t h e d e n t a l e x a m i n a t i o n w a sp e r f o r m e d . T h e o r t h o d o n t ic e x a m i n a ti o n t e a m c o n -s i st ed o f t h e f i rs t a u th o r , a n e x p e r i e n c e d o r t h o d o n -t is t, a n d a d e n t a l n u r s e w h o a c t e d a s a r e c o r d e r . T h eI n d e x o f O r t h o d o n t i c T r e a t m e n t N e e d ( I O T N ) 4 w a su s e d t o a s s e s s t h e l e v e l o f m a l o c c l u s i o n i n e a c ha d o l e s c e n t e x a m i n e d . B e f o r e t h e s u r v e y w a s b e g u n ,t h e e x a m i n e r r e c e i v e d e x t e n s iv e t ra i n i n g a n d i n -s t r u c t i o n i n t h e I O T N . A c a l i b r a t i o n e x e r c i s e w a ss u c c e s s fu l l y c o m p l e t e d i n v o lv i n g s c h o o l c h i l d r e nf r o m a s c h o o l n o t i n c l u d e d i n t h e m a i n s t u d y .

I O T N is c o m p o s e d o f tw o i n d e p e n d e n t b u t c o m -p l e m e n t a ry c o m p o n e n t s. O n e c o m p o n e n t r e c o r d s t hed e n t a l h e a l t h n e e d f o r o r t h o d o n t i c t r e a t m e n t . T h eo t h e r c o m p o n e n t r e c o r d s t h e e s t h et i c n e e d f o r o r t h o -d o n t i c t r e a t m e n t . T h e D e n t a l H e a l t h C o m p o n e n tc o m p r i s e s a 5 - g r a d e s c a l e , a n d t h e A e s t h e t i c C o m p o -n e n t c o n s i s ts o f a 1 0 - g r a d e s t a n d a r d i z e d r a n k i n g s c a l eo f d e n t a l a t t ra c t i v e n e s s . A f t e r a l a r g e v a l i d a t i o n e x e r -c i s e t h e D e n t a l H e a l t h C o m p o n e n t g r a d e s a n d t h eA e s t h e t i c C o m p o n e n t g r a d e s w e r e g r o u p e d i n t o t h r e et r e a t m e n t n e e d c a t e g o r i e s r e p r e s e n t i n g n o n e e d f o ro r t h o d o n t i c t r e a t m e n t , b o r d e r l i n e n e e d , a n d d e f i n i t en e e d f o r o r t h o d o n t i c tr e a t m e n t , s T h e D e n t a l H e a l t hC o m p o n e n t g r a d e s 1 a n d 2 a n d A e s t h et ic C o m p o n e n tg r a d e s 1 t h r o u g h 4 r e p r e s e n t n o n e e d f o r t r e a t m e n t .T h e D e n t a l H e a l t h C o m p o n e n t g r a d e 3 a n d A e s t h e ti cC o m p o n e n t g r a d e s 5 t h r o u g h 7 r e p r e s e n t a b o r d e r l i n en e e d f o r t r e a t m e n t . T h e D e n t a l H e a l t h C o m p o n e n tg r a d e s 4 a n d 5 a n d A e s t h e t i c C o m p o n e n t g r a d e s 8t h r o u g h 1 0 r e p r e s e n t a d e f i n it e n e e d f o r t r e a t m e n t .

W h e r e t h e D e n t a l H e a l t h a n d A e s t h e t i c t r e a t m e n tn e e d c a t e g o r i e s d i f f er f o r t h e s a m e p a t i e n t , t h e n e e df o r t r e a t m e n t i s b a s e d o n t h e w o r s t c a t e g o r y r e c o r d e d .

I n a d d i t i o n t o t h e a s se s sm e n t o f m a l o c c l u s i o n ,e a c h a d o l e s c e n t w as e x a m i n e d f o r t h e p r e s e n c e o fd e n t a l c a r i e s u s i n g t h e c r i t e r i a r e c o m m e n d e d b y t h eW o r l d H e a l t h O r g a n i z a t i o n f o r o r a l h e a l t h s u r v e y s .6T h e o r a l h e a l t h a s se s sm e n t i n c l u d e d a v i su a l e x a m i n a -t i o n f o r t h e p r e se n c e o f p l a q u e , c a l c u lu s , o r g i n g iv a li n f l a m m a t i o n a t f o u r s i te s in t e r o r a ll y . E a c h a d o l e sc e n tw a s a l so a sk e d t o r a t e h i s o r h e r l e v e l o f a n x i e t y a b o u td e n t a l t r e a t m e n t w i t h a 5 - p o i n t s c a l e . 7 O n t h i s s c a l en u m b e r 1 in d i c a t e d a h i g h l e v el o f a n x ie t y a b o u t d e n t a lt r e a t m e n t , a n d n u m b e r 5 r e p r e s e n t e d n o a n x i e t y a b o u td e n t a l t r e a tm e n t . T h e f r e q u e n c y o f d e n t a l a t t e n d a n c eo f e a c h s u b j e c t a n d t h e f r e q u e n c y o f t h e ir p a r e n t s 'd e n t a l a t t e n d a n c e w a s r e c o r d e d . I f t h e s u b j e c t a t-t e n d e d t h e d e n t i s t a t le a s t o n c e a y e a r , h e o r sh e w a sc o n s i d e r e d t o b e a r e g u l a r d e n t a l a t t e n d e r . E a c hsu b j e c t w a s a l so a sk e d a b o u t p r e v i o u s , p r e se n t , o rp l a n n e d o r t h o d o n t i c tr e a t m e n t o r w h e t h e r h e o r s h eh a d b e e n o f f e r e d o r t h o d o n t i c t re a t m e n t .

S e l f - p e r c e p t io n o f m a l o c c l u s io n w a s e v a l u a t e db y a s k in g e a c h c h i l d t o r a t e h i s o r h e r o w n d e n t a la t t r a c t i v e n e s s w i t h a 1 0 - p o i n t l i n e a r n u m e r i c s c a l e .T o a s s i s t t h e a d o l e s c e n t i n r a t i n g h i s o r h e r d e n t a la t t r a c ti v e n e s s , a p h o t o g r a p h o f a n a t t r a c t i v e d e n t i -t i o n w it h r e g u l a r t e e t h w a s p l a c e d a t n u m b e r 1 o nt h e s c a le . A p h o t o g r a p h o f an u n a t t r a c t i v e d e n t i t i o nw i t h i rr e g u l a r t e e t h w a s p l a c e d a t t h e o t h e r e n d o ft h e s c a le , t h e n u m b e r 1 0 p o s i t i o n . T h i s t e c h n i q u eh a s b e e n u s e d i n p r e v i o u s s t u d i e s , a n d w i t h i n t h et i m e c o n s t r a i n t s o f a s c h o o l d e n t a l s c r e e n i n g e x e r -c i s e t h e m e t h o d h a s b e e n f o u n d t o b e q u i c k a n de a si ly u n d e r s t o o d b y s c h o o l c h il d r e n . 8S o c i o e c o n o m i c S t a tu s

T h e s o c i o e c o n o m i c b a c k g r o u n d o f e a c h s u b j e ctw a s d e t e r m i n e d f r o m t h e p o s t c o d e ( z i p c o d e ) o f h is o rh e r h o m e a d d r e s s w it h a n a r e a - b a s e d co m p o s i t e m e a -sure of soc ia l i nequa l i ty , t he Mosiac c l a ss i f i ca t ions y s t e m ( C C N M a r k e t i n g , N o t t i n g h a m , U . K . ) . M o s i a cis a g e o g r a p h i c n e i g h b o r h o o d c l a ss i f ic a t io n sy s t e m t h a th a s b e e n b u i lt w i th i n f o r m a t i o n f r o m a v a r i et y o fso u r c e s i n c l u d i n g t h e e l e c t o r a l r o l l , t h e c e n su s , c r e d i ta c t i v i t y , t h e N o r t h e r n I r e l a n d H o u s i n g S u r v e y , a n dp l a n n i n g a p p l i c a t i o n s . I n N o r t h e r n I r e l a n d a p p r o x i -m a t e l y 5 8 0 , 0 0 0 h o u se h o l d s a r e a l l o c a t e d t o 4 1 , 0 0 0p o s t c o d e s . E a c h p o s t c o d e c o n t a i n s a n a v e r a g e o f 1 5h o u se h o l d s . S t a t i s t i c a l c l u s t e r i n g t e c h n i q u e s a r e u se dt o a n a l y z e a r a n g e o f d e m o g r a p h i c , s o c i o e c o n o m i c ,a n d h o u s i n g v a r i a b l es . O n t h e b a s i s o f t h e se s t at i st i cse a c h p o s t c o d e h a s b e e n a l l o ca t e d a M o s i a c t y p e f r o m

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4 1 0 Br e i s te in a n d B u rd en American Journal of Orthodontics and Dentofac ial OrthopedicsApril 1998

T a b l e I. The characteristics of the adolescents examinedSex Female Male754 (48%) 830 (52%)Religion Catholic Protestant

827 (52%) 757 (48%)Socioeconomic status Above average Average395 (24.9%) 656 (41.4%)Local availability of Good Averageorthodontic care 503 (31,8%) 614 (38.8%)

Below average Unclassified474 (29.9%) 59 (3.8%)Poor467 (29.5%)

I to 30 describing the characteristics of the householdscontained within it. For the purposes of this investiga-tion the 30 Mosiac types were aggregated into socio-economic groups of above average, average, and belowaverage circumstances.R e l i g i o u s A f f i li a t io n

In Northern Ireland it is considered inappropri-ate in surveys involving children to inquire in to the irreligious affiliation. However, epidemiologists havedeveloped techniques by which data on this variablecan be collected indirectly. In law, all schools inNorthern I reland are open to all pupils regardless ofreligion. In practice, however, the vast majority ofProtestant children attend "state" schools, whereasCatholic children are enrolled in separate Catholicschools. This dichotomy in schools attended is espe-cially evident for primary schools (grade schools).The government accepts this as an expression ofparental wishes and does not seek to impose inte-grated schools. Therefore in this study the religiousaffiliation of each subject was de termined from theprimary school attended.S t a t i s t i c a l A n a l y s i s

The logistic regression technique was used tocompare the characteristics of those adolescentswho received orthodontic treatment with those whowere rated as having a definite need for treatmentand yet did not receive treatment or advice.R E S U L T STo test intraexaminer reproducibility, 20 of thechildren were reexamined 6 weeks af ter their initialexamination. Examiner reproducibility for theIOTN was assessed with the weighted Kappa statis-tic. 9 Weighted Kappa values for the Dental HealthComponent and the Aesthetic Component were0.80 and 0.90, respectively; Kappa values o f 0.8 andabove indicate good agreement.T h e R e s p o n se

The survey relied on cooperation at three stagesbefore the adolescents could be examined. First, the

consent of the individual schools to involve theirpupils had to be obtained. All those approachedgave their permission with the exception of oneschool. Second, the consent of the parent or guard-ian to examine the child was required. Third, ethicalapproval for this study specified that the informedwritten consent of each adolescent should be ob-tained before the or thodontic examination was per-formed. In addition, the agreement with schools didnot permit repeated visits to pick up absentees;therefore losses occurred because of absences. Intotal, 1584 children were examined in 23 highschools in Northern Ireland out o f a target sample of2172. This gave a response rate of 73%.T h e C h a r a c t e r i s t ic s o f t h e S a m p l e

The average age of the adolescents examinedwas 16.1 years (range 15.0 to 17.4 years). The sex,religious affiliation, socioeconomic status, and localavailability of orthodontic care for the sample arepresented in Table I. The number o f boys and girlsexamined and the number from each religious groupin Northe rn Ireland was well balanced. The Mosiacneighborhood classification system revealed that allsocial strata were represented in the sample. How-ever, for 59 (3.8%) subjects it was not possible toassess the socioeconomic background because thepostcode of their home address related to institu-tions and other nonfamily residences (Table I). Thelocal availability of orthodontists for the subjectsexamined was almost equally divided among good,average, and poor local availability (Table I). Poorlocal availability of orthodontists was particularlyevident in the more rural areas to the south and westof Northern Ireland.T r e a t m e n t N e e d a n d T r e a t m e n t E x p e r ie n c e

With the IOTN 1227 (77.4%) of the subjectswere classified as having no definite need for ortho-dontic treatment (Table II). No definite need wasdefined as those with no need or borderline needaccording to IOTN. Among those adolescents withno definite need for treatment, 322 (20.3%) hadpreviously received orthodontic treatment.

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American Journal of Orthodontics and Dentofacial Orthopedics Br eis tein a n d B ur de n 411Volume 113, No. 4Tab l e I I . The orthodontic treatment need and the treatmentexperience of the adolescents examined

Treatment need(IOTN)No definite need

Definite need

ITreatment experience No. ] Perce ntPrevious treatment 322 20.3No previous treatment 905 57.1Previous treatment 110 7.0Offered treatment and 70 4.4declinedAbout to commence 14 0.9treatmentUnmet need (no previous 163 10.3treatment or offer of

treatment)Total 1584 100

A m o n g t h o s e a d o l e s c e n ts r at e d b y th e I O T N a sh a v i n g a d e fi n i t e n e e d f o r t r e a t m e n t , 1 10 ( 7 . 0 % ) h a dp r e v i o u s ly w o r n a n o r t h o d o n t i c a p p l i an c e , a f u r t h e r7 0 ( 4 .4 % ) h a d b e e n o f fe r e d o r t h o d o n t i c t r e a t m e n ta n d d e c l i n e d , a n d 1 4 s u b j e c t s ( 0 . 9 % ) w e r e a b o u t t oc o m m e n c e o r t h o d o n t i c t r e a t m e n t .

U n m e t n e e d f o r o r t h o d o n t i c t r e a t m e n t w a s d e -f i n e d a s t h o s e s u b j e c t s w i th a d e f i n i t e n e e d f o rt r e a t m e n t w h o h a d n o t r e c ei v e d t r e a t m e n t o r b e e no f f e r e d t r e a t m e n t . O n e h u n d r e d s i x t y- t h re e (1 0 . 3 % )o f t h e a d o l e s c e n t s e x a m i n e d h a d s e v e r e m a l o c c l u -s i o n s a n d y e t h a d n o t r e c e i v e d t r e a t m e n t o r t h e o f f e ro f t r e a t m e n t ( T a b l e I I ) .

T h e l e ve l o f a n x i e ty a b o u t d e n t a l t r e a t m e n t w a sn o t f o u n d t o d i f f e r s i g n if i ca n t ly b e t w e e n t h o s e a d o -l e s c e n t s w h o r e c e i v e d o r t h o d o n t i c t r e a t m e n t a n dt h o s e w h o d i d n o t r e c e i v e t r e a t m e n t ( M a n n - W h i t -n e y , p = 0 . 06 ) . T h e m e a n d e n t a l a n x i e ty r a t i n g f o rt h o s e w h o r e c e i v e d t r e a t m e n t w a s 4 .5 ( S D 0 .9 ) a n df o r t h o s e w h o d i d n o t r e ce i ve o r t h o d o n t i c t r e a t m e n twas 4 .4 (SD 1 .0) .

W i t h t h e 1 0 - p o i n t l i n e a r s c a l e t h e a d o l e s c e n t sw i t h a d e f i n i t e n e e d f o r o r t h o d o n t i c t r e a t m e n tt e n d e d t o r a n k t h e i r d e n t i t i o n s a s l e s s a t t r a c t i v e( m e a n 4 .2 , S D 1 .4 ) t h a n t h o s e w h o h a d n o n e e d o rb o r d e r l i n e n e e d f o r t r e a t m e n t ( m e a n 3 . 5 , S D 1 . 5 ) .A n a ly s i s r e v e a l e d t h a t t h i s d i f f e r e n c e i n s e l f - r a t e dd e n t a l a t t r a c t i v e n e s s b e t w e e n t h e t w o g r o u p s w a ss ig n i f i c a n t ( M a n n - W h i tn e y , p < 0 . 0 01 ) .

L o g i s t ic r e g r e ss i o n a n a ly s i s w a s u s e d t o c o m p a r et h o s e s u b j e c t s w i t h u n m e t o r t h o d o n t i c t r e a t m e n tn e e d ( n = 1 6 3) w i t h t h o s e s u b j ec t s w h o h a d r e c e i v e dt r e a t m e n t o r b e e n o f fe r e d t r e a t m e n t o r w e r e a b o u tt o c o m m e n c e o r t h o d o n t i c tr e a t m e n t ( n = 5 16 ).I n i t i al l y , 1 1 e x p l a n a to r y v a r i a b l e s t h a t m ig h t b ec o n s i d e r e d t o i n f l u e n c e t h e r e c e i p t o f o r t h o d o n t i c

T a b l e IlL Logistic regression model predicting the liklihood ofan adolescent receiving orthodontic care (after elimination ofnonsignificant variables)

Odds I SignificanceExplanatory variable ratio (9 5% CO (p Value)

Frequency of mother's dental 2.41 (1.57-3.70)

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412 Breistein and Burden American Journal of Orthodontics and Dentofacial OrthopedicsApril 1998

i n d e e d so c i a l j u s t i c e w o u l d d i c t a t e , t h a t o r t h o d o n t i cc a r e sh o u l d b e a c c e s s i b l e t o a l l c h i l d r e n w h o h a v e ah i g h o b j e c t i v e n e e d f o r t r e a t m e n t . T h e e q u i t y o rf a ir n e s s o f a n y o r t h o d o n t i c s e r v ic e c a n o n l y b e e s t ab -l is h e d b y c o n d u c t i n g p r o p e r l y d e s i g n e d e p i d e m i o l o g i cs t u d i e s t h a t e x p l o r e t h e i n f l u e n c e o f so c ia l , e c o n o m i c ,a n d e t h n i c v a r ia b l e s o n t h e r e c e i p t o f o r t h o d o n t i ct r e a t m e n t . T h e m a i n a i m o f th i s s tu d y w as t o d e t e r -m i n e w h e t h e r a l l c h i l d r e n i n N o r t h e r n I r e l a n d h a v ee q u a l o p p o r t u n i t y t o r e c e i v e o r t h o d o n t i c c a r e i f t h e yn e e d i t i r r e sp e c t i v e o f t h e i r so c i a l , e c o n o m i c , o r r e l i -g i o u s b a ck g r o u n d . F o r v a l i d co n c l u s io n s t o b e m a d e i ns t u d i e s o f t h i s n a t u r e , t h e c h a r a c t e r is t i c s o f t h o sec h i l d r e n w h o h a v e r e c e i v e d o r t h o d o n t i c t r e a t m e n tm u s t b e c o m p a r e d w i th t h o s e w h o n e e d t r e a t m e n t a n dy e t d o n o t r e c e i v e t r e a t m e n t o r t h e o f f e r o f t r e a t m e n t .I n a d d i t i o n , i t is a l so i m p o r t a n t i n t h i s t y p e o f s t u d y t oe x a m i n e s u b j e c t s a t a n a g e w h e n o r t h o d o n t i c t r e a t -m e n t h a s u s u al ly b e e n c o m p l e t e d o r h a s s t a r t ed . I n t h eU n i t e d K i n g d o m s t u d i e s h a v e s h o w n t h a t 9 7 % o fc h i l d r e n w h o r e c e i v e o r t h o d o n t i c t r e a t m e n t d o s ob e f o r e t h e a g e o f 1 5 y ea r s .3 T h e r e f o r e t h e s a m p l e o fa d o l e sc e n t s s e l e c t e d f o r e x a m i n a t i o n i n t h is s t u d y w e r ea t a n a g e w h e n o r t h o d o n t i c t r e a t m e n t h a s u s u a ll yf i n i sh e d o r is o n g o i n g .

A p p r o x i m a t e l y o n e t h i r d ( 2 8 % ) o f th e 1 5- a n d1 6 - y e a r - o l d s e x a m i n e d i n N o r t h e r n I r e l a n d h a d r e -c e i v e d o r w e r e a b o u t t o r e c e i v e o r t h o d o n t i c t r e a t-m e n t . T h i s i s v e r y s i m i la r t o t h e n a t i o n a l a v e r a g e f o rt h e U n i t e d K i n g d o m r e p o r t e d i n t h e 1 9 93 C h il dD e n t a l H e a l t h S u r v e y .2 T h i s l a t t e r s u r v e y d i s c o v e r e dt h a t o n a v e r a g e 2 7 % o f 1 5 - y e a r- o ld s i n t h e U n i t e dK i n g d o m h a d r e c e i v e d o r w e r e a b o u t t o r e c e iv eo r t h o d o n t i c t r e a t m e n t .

W i t h t h e I O T N 2 2 . 6 % o f t h e a d o l e s c e n ts e x a m -i n e d w e r e c o n s i d e r e d t o b e i n d e f i n i t e n e e d o fo r t h o d o n t i c t r e a t m e n t . H o w e v e r , s o m e o f t h e s ec h i l d r e n h a d b e e n o f f e r e d o r t h o d o n t i c t r e a t m e n ta n d d e c l i n e d o r w e r e a b o u t to c o m m e n c e t r e a t m e n t .S e v e n p e r c e n t o f th e s c h o o l c h i ld r e n e x a m i n e d int h is s t u d y h a d p r e v i o u s ly w o r n a n o r t h o d o n t i c a p p l i-a n c e a n d y e t s ti ll h a d a h i g h o b j e c t i v e n e e d f o ro r t h o d o n t i c t re a t m e n t . A l t h o u g h t h e r e s o u r c e im -p l i c a t io n s a r e s e l f - e v i d e n t , tw o p o s s i b l e e x p l a n a t i o n se x i s t f o r t h i s a p p a r e n t f a i l u r e t o p r o d u c e a s i g n i f i -c a n t i m p r o v e m e n t i n t h e o r t h o d o n t i c c o n d i t i o n o ft h e s e c h i l d r e n . F i r s t , t h e c h i l d m a y h a v e f a i l e d t oc o m p l e t e t h e p r e s c r i b e d c o u r s e o f o r t h o d o n t i c c a re .H a y n e s a~ r e p o r t e d t h a t a p p r o x i m a t e l y 2 0 % o f c h i l-d r e n w h o c o m m e n c e o r t h o d o n t i c t r e a tm e n t in t h eU n i t e d K i n g d o m f a i l t o c o m p l e t e t h e i r c o u r s e o fo r t h o d o n t i c t r e a t m e n t . S e c o n d , o r t h o d o n t i c t r e a t -m e n t m a y h a v e f a il e d b e c a u s e o f i n c o r r e c t d i a gn o s i s

o r t r e a t m e n t o n t h e p a r t o f t h e c li ni ci an . R e c e n ts t u d ie s o f t h e r e s u l ts o f o r t h o d o n t i c t r e a t m e n t c a r -r i e d o u t in th e U n i t e d K i n g d o m a n d e l s e w h e r e h a v ep a r t i c u l a r l y h i g h l i g h t e d t h e l o w e r s u c c e s s r a t ea c h i e v e d w h e n t r e a t i n g m i l d m a l o c c l u s io n s , e s p e -c i a ll y w i t h r e m o v a b l e a p p l i a n c e s , la,a2

W h e n t h o s e s u b j e c ts w h o h a d p r e v i o u s l y r e c e i v e do r t h o d o n t i c t r e a t m e n t o r t h e o f f e r o f t r e a t m e n t w e r ee x c l u d e d , i t w a s f o u n d t h a t 1 i n 1 0 a d o l e sc e n t s i nN o r t h e r n I r e l a n d h a d a n u n m e t n e e d f o r o r t h o d o n t icc a r e . T h e se i n d i v id u a l s h a d a h i g h o b j e c t iv e n e e d f o ro r t h o d o n t i c t r e a t m e n t a n d y e t h a d n o t r e c e i v e d tr e a t-m e n t o r t h e o f f e r o f t r e a tm e n t .

S t u d i e s h a v e r e v e a l e d t h a t i n e q u a l i t i e s d o e x i s ti n th e d e l i v e r y o f h e a l t h c a r e i n t h e U n i t e d K i n g -d o m . la S i m i l a r i n e q u a l it i e s i n h e a l t h c a r e h a v e b e e ns h o w n t o e x i s t i n n e a r l y a l l W e s t e r n s o c i e t i e s a n dr e p r e s e n t o n e o f t h e b i g g e s t c h a l l e n g e s t o g o v e r n -m e n t s t h r o u g h o u t t h e w o r l d . 14 I n t h e U n i t e d K i n g -d o m i t h a s b e e n s h o w n t h a t s o c i o e c o n o m i c b a c k -g r o u n d c a n e x e r t a m a j o r i n f l u e n c e o n t h e u p t a k e o fh e a l t h c a r e , w i t h l o w e r s o c i o e c o n o m i c g r o u p s l e s sl i k e l y t o a c c e s s t h e h e a l t h s e r v i c e s a v a i l a b l e . 13 I nr e l a t io n t o o r t h o d o n t i c t r e a t m e n t , t h e e x a c t i nf lu -e n c e o f s o ci a l c l as s r e m a i n s u n c l e a r . S o m e s t u d i e sh a v e s u g g e s t e d t h a t s o c i a l c l a s s i s a n i m p o r t a n tc o n s i d e r a t i o n , w i t h m o r e c h i l d r e n f r o m h i g h e r s o -c i o e c o n o m i c g r o u p s r e c e i v i n g t r e a t m e n t . 15,16 O t h e rs t u d i e s h a v e i n d i c a t e d t h a t s o c i a l c l a s s p e r s e m a yn o t b e a s i m p o r t a n t a s o n c e t h o u g h t i n d e t e r m i n i n gw h e t h e r o r t h o d o n t i c t r e a t m e n t i s r e c e i v e d . 17,~8 M o s to f th e p r e v i o u s s tu d i e s t h a t e x a m i n e d t h e i n f l u e n c eo f s o c ia l c la ss o n t h e u p t a k e o f o r t h o d o n t i c t r e a t-m e n t h a v e u s e d t h e o c c u p a t i o n o f t h e h e a d o fh o u s e h o l d t o c a t e g o r i z e a f a m i l y ' s s o c i o e c o n o m i cs t a tu s . H o w e v e r , s u c h a n a p p r o a c h h a s l i m i t a t io n s i nt e r m s o f g a i n i n g s u f f i c ie n t ly p r e c i s e i n f o r m a t i o n f o rc l a s si f ic a t io n a n d m a y m i s j u d g e t h e e c o n o m i c p o si -t i o n o f f a m i l ie s w i th t w o e a r n e r s . A l t e r n a t i v e a r e a -b a s e d c o m p o s i t e m e a s u r e s o f s o c i al i n e q u a l i t y s u c ha s u s e d i n t h is s t u d y c o m b i n e d e m o g r a p h i c , h o u s i n g ,a n d e m p l o y m e n t c h a r a c te r i st ic s a n d h a v e t h e r e f in e -m e n t t o i d e n t i f y g r o u p s t h a t a r e p a r t i c u l a r l y d is a d -v a n t a g e d i n t e r m s o f h e a l t h ) 9 T h e s y s t e m is d i re c t l ya p p l i c a b l e t o a l l g r o u p s i n t h e p o p u l a t i o n , a n d o n l yt h e p o s t c o d e ( z i p c o d e ) i s r e q u i r e d f o r c l a s s if i c at io n .

W h e n t h e i n f l u e n c e o f s o c i o e c o n o m i c b a c k -g r o u n d o n t h e u p t a k e o f o r t h o d o n t i c t r e a t m e n t w a sa s se s se d i n t h i s s t u d y w i t h t h e l o g i s t i c r e g r e s s i o nm o d e l , n o s i g n i f i c a n t r e l a t i o n s h i p w a s d e t e c t e d .

N e a r l y o n e t h i r d o f t h e a d o l e s c e n ts e x a m i n e dl i v e d i n a n a r e a c o n s i d e r e d t o h a v e p o o r l o c a la v a i la b i li t y o f o r t h o d o n t i s t s . N o n e t h e l e s s , n o s i g n if -

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American Journal of Orthodontics and Dentofacial Orthopedics Breistein and Burden 413Volume 113, No. 4

i c a n t r e l a t i o n s h i p w a s d e t e c t e d b e t w e e n t h e l o c a la v a il a b il it y o f o r t h o d o n t i s t s a n d t h e l e v e l o f u n -t r e a t e d m a l o c c l u s i o n . T h i s f i n d i n g is l ik e l y t o b e d u et o t h e f a c t t h a t N o r t h e r n I r e l a n d i s a s m a l l c o u n t r yw i t h a g o o d i n f r a s t r u c t u r e . C h i l d r e n l iv i ng in r e g i o n sw i t h p o o r l o c a l a v a i l a b i l i t y o f o r t h o d o n t i s t s c a nt r a v e l w i t h r e l a t iv e e a s e t o a r e a s w h e r e t h e r e a r em o r e p r o v i d e r s o f o r t h o d o n t i c t r e a t m e n t .

I t i s a l s o i n t e r e s t i n g t h a t a n x i e t y a b o u t d e n t a lt r e a t m e n t d i d n o t a p p e a r t o a c t a s a s i g n i f i c a n tb a r r i e r p r e v e n t i n g i n d iv i d u al s i n n e e d o f t r e a t m e n tf r o m e n t e r i n g o r t h o d o n t i c t r e a t m e n t . T h e l i k e l ye x p l a n a t i o n f o r t h is f i n d in g i s t h a t o r t h o d o n t i c t r e a t -m e n t i s p e r c e i v e d t o b e o n e o f t h e l es s p a i n f u l f o r m so f d e n t a l t r e a t m e n t .

I n t h e c o n t e x t o f t h e p r o b l e m s t h a t a r e p e c u l i a r t oN o r t h e r n I r e l a n d , i t i s a l so p a r t i c u l a r l y r e a s su r i n g t of i n d t h a t a c h i l d ' s r el i g i o n d i d n o t a c t a s a b a r r i e r t o t h er e c e i p t o f o r t h o d o n t i c c a r e. I n s t e a d, t h e f r e q u e n c y o ft h e a d o l e sc e n t ' s d e n t a l a t t e n d a n c e , t h e i r l e v e l o f d e n -t a l h e a lt h , a n d t h e f r e q u e n c y o f t h e i r m o t h e r ' s d e n t a la t t e n d a n c e a p p e a r e d t o b e t h e o n l y s i g n i f i c a n t v a r i -a b l e s t h a t e x p l a i n e d t h e f a i l u r e t o r e c e i v e t r e a t m e n t .D e t a i l s a b o u t t h e a d o l e sc e n t ' s d e n t a l a t t e n d a n c e a n dh is o r h e r p a r e n t s ' d e n t a l a t t e n d a n c e w e r e c o l l e c t e d b yi n t e rv i e w i n g e a c h su b j e ct . T h e v a l i d it y o f t h i s a p p r o a c hc o u l d b e q u e s t i o n e d , b u t i t w a s b e l i e v e d t h a t 1 5 - a n d1 6 - y e a r -o l d s w o u l d b e a b l e t o p r o v i d e a r e a so n a b l ya c c u r a t e r e sp o n se t o t h e se q u e s t i o n s .

I n t h e U n i t e d K i n g d o m n e a r l y a l l p a t i e n t s a c c e s so r t h o d o n t i c t r e a t m e n t t h r o u g h t h e i r g e n e r a l d e n -t a l p r a c t i t i o n e r , w h o f u l fi ls th e i m p o r t a n t r o l e o f" g a t e k e e p e r " t o t h e o r t h o d o n t i c s e r v i ce , z ~ I t i st h e r e f o r e n o t s u r p r is i n g t h a t c h i l d r e n a n d t h e i rp a r e n t s w h o h a v e i n f r e q u e n t c o n t a c t w it h g e n e r a ld e n t a l p r a c t i t i o n e r s a r e l e s s li k e ly to a c c e s s o r t h o -d o n t i c c a r e . T h i s r e l a t i o n s h i p b e t w e e n t h e f r e -q u e n c y o f d e n t a l a t t e n d a n c e a n d t h e r e c e i p t o fo r t h o d o n t i c t r e a t m e n t h a s a ls o b e e n n o t e d i no t h e r s t u d i es . 21 C h i l d r e n w h o d o n o t v i s it a d e n t i s to n a r e g u l a r b a s i s a r e a l s o m o r e l i k e l y t o h a v es u b o p t i m a l d e n t a l h e a l t h a n d a r e l es s l ik e l y t o b er e f e r r e d f o r o r t h o d o n t i c c a r e .

A l t h o u g h n o i n h e r e n t i n e q u a l it y o r u n f a i r n es s w a se v i d e n t in t h e d e l iv e r y o f o r t h o d o n t i c c a r e i n N o r t h e r nI re l and , i t i s s t i l l appa ren t t ha t a s ign i f i can t p ropor t iono f c h i ld r e n i n c l e ar n e e d d o n o t a c c e s s t r e a t m e n t . T h eq u e s t i o n r e m a i n s w h e t h e r i t m a t t e r s t h a t c h i l d r e n w i t hs e v e r e m a l o cc l u s io n d o n o t r e c e iv e t r e a t m e n t o r a d v i cea b o u t a v a i l ab l e s e rv i ce s . I t c o u l d b e a r g u e d t h a t t h e sec h i l d re n h a v e n o t r e c e i v e d t r e a t m e n t b e c a u s e t h e y a r eh a p p y w i t h t h e i r d e n t a l a p p e a r a n c e . H o w e v e r , t h er e su l ts o f t h is su r v e y i n d i c a t e t h a t t h e c h i l d r e n w i t h a

d e f i n i t e n e e d f o r o r t h o d o n t i c t r e a t m e n t p e r c e i v e dt h e i r d e n t i t i o n s t o b e l e s s a t t r a c t i v e t h a n t h e i r p e e r sw i t h n o o r b o r d e r l i n e o r t h o d o n t i c n e e d .CONCLUS I O NSThis study rev ealed that no inequality ex ists in thedel ivery of or thodo nt ic care in North ern Ire land. Non ethe-less, 1 in 10 children failed to receive treatm ent, ev en thou ghthey had a high object ive need for or thodont ic t reatment .Th e results showed that th e chi ldren wi th unme t or thodo nt icneed w ere mo re l ikely to be i rregular dental a t tenders andmo re likely to have poo r dental health. Encouraging m oreregular a t tend ance am ong those chi ldren w ho infrequent lyvisi t the dent ist may help to reduce the proport ion ofuntreated malocclusion in N orthern Ireland.

The au thors acknowledge the coo pera t ion and pa r t i c -ipat ion of the adolescents who took part in this study.

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