New patients, accepted for orthodontic treatment were disclosed with PaqSearchTM disclosing dye and completed our aforementioned questionnaire. This process was repeated for 5 new patient clinics within that month. The same sample was then followed up at a later date once each patient had attended one appointment atthe nurse-led oral hygiene clinic. Again, repeat plaque and questionnaire scoreswere recorded,with anadditionalpatient satisfaction component incorporated into the questionnaire. Results were tabulated on Microsoft Excel © and compared to the standards.

Introduction

Background

In order to ensure safe and efficient patient care, itis important that primary and secondary care professionals give consistent, evidence based messages regarding oral disease prevention, particularly in today’s emphasis on prevention of ill-health. Orthodontic patients fall into a high caries risk bracket thus preventive advice should be provided at a greater intensity [1]. Furthermore, poor oral hygiene is a predicting factor for patients failing to complete orthodontic treatment and achieving unsatisfactory results [2]. Responsibility for oral hygiene (OH) optimisation should start within primary care and should be occurring prior to referral. Despite this, some patient’s standards can drop from point of referral to presentation in secondary care. An audit was proposed due to concerns regarding the dental health and oral health knowledge of a proportion of new orthodontic patients being referred to Northampton General Hospital (NGH).

NGH: Northampton General Hospital; OH: Oral Hygiene.

1. Establish current OH levels of new patients via plaque score readings.
2. Quantify patient knowledge of oral health within sample.
3. To design a patient centred service for preventive care.

1. Plaque scores ≤ 20% [3, 4] for 100% of new patients, prior to bond-up.
2. 2≥ 80% OH knowledge for 100% of patients.

The sample consisted of consecutive newpatients (regardless of age, malocclusion and number of teeth present) accepted for any form of NHS orthodontic treatment, at NGH. A data collection period of 1 month, starting on 25/11/2015 and ending on 21/12/15 was set. Patients would belong to one of the two consultant orthodontists working within our department. A onemonth period was chosen, on the proviso that if all 5 new-patient clinics listed on our software were utilised, a reasonable sample size would be achievable. Each clinic consists of approximately ten patients. The O’ Leary plaque index [5] was used as a representation of oral hygiene level and a locally made, eleven-part questionnaire was used to quantifypatient’s knowledge onoralhealth(Figure 1). Each question asked patients about their perceived knowledge level on various aspects of oral health maintenance relative to what the Delivering Better Oral Health toolkit (Public Health England) stipulated as important for orthodontic patients.

Figure 1: Results demonstrating plaque levels (%) of each new patient in sample across both cycles, set against the median and standard.

Our prospective audit was criterion based for both cycles.

New patients, accepted for orthodontic treatment were disclosed with PaqSearchTM disclosing dye and completed our aforementioned questionnaire. This process was repeated for 5 new patient clinics within that month. The same sample was then followed up at a later date once each patient had attended one appointment atthe nurse-led oral hygiene clinic. Again, repeat plaque and questionnaire scoreswere recorded,with anadditionalpatient satisfaction component incorporated into the questionnaire. Results were tabulated on Microsoft Excel © and compared to the standards.

14 patients (8–25 years) formed our sample with a median age of 15. The female to male gender split was 10:4. Plaque scores: 5 out of 14 patients (36%) achieved a plaque score of less than or equal to 20%. This did not meet the standard set. The median was 24.75% (Figure 2). Oral Hygiene Knowledge questionnaire: Only 1 patient (7.1%) achieved a knowledge score of ≥ 80%. This did not meet the standard set. The median was 58.15% and the mean was 54% (Figure 3). After the oral hygiene intervention, 85.7% (6/7) achieved a plaque score of ≤ 20%. Of the 6 patients who achieved the standard, an improvement was noted in 4. With regards to the perceived knowledge levels, 75% (6/8) achieved the set standard with all but one of these patients improving upon their knowledge compared to the first cycle.

Figure 2: Results demonstrating knowledge levels (%) of each new patient in sample, across cycles, set against the median and standard.

The sample size was lower than anticipated due to a limiteddatacollectionperiod.This lowsamplesizeindicated that using the median was more representative than a mean for reporting the results. In hindsight a longer time frame for data collection would have been ideal to achieve a larger sample. The patient drop outs occurred due to patients failing to attend orthodontic appointments within our audit time parameters or parents were not willing to attend an extra visit for data collection. The age variance meant two patients (aged 9 years and 8 years, respectively) required support from their parents to complete the questionnaire which created a bias. The lowest plaque score in the sample was from a child whom was under care within the Cleft service. He had already received significant oral health advice and so ensured he maintained pristine oral hygiene.

The questionnaire was designed without a pilot or previous research however a strong evidence base relevant to oral hygiene maintenance during orthodontic treatment was used. This meant it was able to show deficiencies in particular aspects of oral health maintenance and, as it was useful for measuring what it set out to measure, the team felt it could be considered valid for this study. For the 5 patients who achieved the desired plaque level, their mean plaque level was only 12% however their knowledge level was 61% - still shy of the standard. This demonstrates there was a need to educate new patients regardless of their preoperative oral hygiene levels, particularly as maintaining oral hygiene post bond up is more challenging. Plaque scores improved in 4/7 patients. However, for the remaining three patients, two met the required standard in both cycles. Overall the median plaque scores did decrease markedly across both cycles. Perceived knowledge levels improved in all but one patient. This patient however did achieve the desired plaque levels in both cycles so we anticipate that she may have over-scored herself during the first cycle. The median in cycle 2 surpassed the standard demonstrating the effectiveness of our interventions. This sentiment was echoed in the patient satisfaction questionnaire we utilised which produced a median satisfaction level of 88.75% (Figure 3).

Figure 3: Results illustrating patient satisfaction level (%) with nurse led service.

After the first cycle, an initial meeting between the audit team, department manager, and department lead resulted in a. It has been reported that there is no significant difference between three different teaching methods (written, one-to-one and video) for improving oral hygiene knowledge and concluded that no one method will suit everyone. Our recommendations, which were implemented after the first cycle, are based upon education using a number of different methods in order to maximise the impact [6] decision that nurse-lead oral health clinics would be a useful way to address the above issues.

Multiple interviews took place as a follow up to our staff meeting:

1. Staff from an existing hospital orthodontic department utilising nurse lead oral health clinics gave us good insight into planning a nurse-led service.
2. An orthodontic specialist in practice suggested how optimisation occurs in the community.
3. Feedback via questionnaires from our department hygienist and staff nurses enabled good understanding of staff availability and interest in participation.
4. Commence nurse-lead clinics, operating twice a month, with nurse are trained in-house following guidance from Delivering Better Oral Health (2014). The two trained nurses will work under ‘extended duties’ of their nursing qualifications, and follow a proforma which would act as a clinical document to be filed in patient notes.
5. Create a clinical leaflet on oral health maintenance for the orthodontic patient including consequences ofpoor oral hygiene based on the findings of our audit to supplement the BOS leaflets given already.
6. Create a product list of all essential aids required to maintain good hygiene.

We would like to thank staff nurses, Anna Desborough and Sue May for leading these clinics and also thank Sister Hicks in assisting in the set-up of these clinics.

1. Public Health England. Delivering Better Oral Health: an evidence-based toolkit for prevention. 3rd ed. London: 2014.
2. Mandall NA, Matthew S, Fox D, et al. Prediction of compliance and completion of orthodontic treatment: are quality of life measures important? Euro J Orthod 2008; 30(1): 40-45.
3. Arkutu N, Scholey JM and Curly A. Orthodontic Education Clinics – An audit on oral hygiene and dental knowledge. British Orthodontic Society, Clinical Effectiveness Bulletin 2009; 22(1):18 - 19.
4. Rakhshan H, Rakhshan V. Effects of the initial stage of active fixed orthodontic treatment and sex on dental plaque accumulation. A preliminary cohort study SDJR 2015; 6(2): 86 – 90.
5. O Leary T, Drake R and Naylor. The plaque control record. J Periodontol 1972; 43(1): 38-39.
6. Lees A and Rock WP. A comparison between written, verbal and videotape oral hygiene instruction for patients with fixed appliances. J Orthod 2000; 27(4): 323-328.