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Objectives: To identify key measures in predicting orthodontic treatment need and to propose a self-assessment instrument that improves treatment need assessment., Subjects and Methods: The study included 150 randomly selected 13-year-olds. A set of measures linked to a previous study on daily life impact of malocclusion was processed, resulting in an instrument, the Demand for Orthodontic Treatment Questionnaire (DOTQ), which was analysed regarding dimensionality, reliability and validity. Dental Health Component of the Index of Orthodontic Treatment Need (IOTN-DHC) grading, representing professionally assessed treatment need, were collected from dental records. The instrument's ability to predict treatment need was tested by randomly splitting the dataset into two subgroups, using multiple regression to predict DHC in one of the groups and the prediction equation to calculate predicted DHC in the other. The outcomes were then correlated to detect the predictive power of the DOTQ, and thereby the validity of the prediction., Results: The DOTQ-measures were reliable and highly inter-correlated. A high, significant correlation was found between assessed and predicted treatment need for the subgroups (r = 0.59 and 0.49), confirming the validity of the prediction. Independent variables (the measures) explained 47 per cent (R = 0.69) of the variance in treatment need. Four measures contributed significantly to the prediction, with Treatment Demand being the most powerful predictor., Limitations: The age group and response rate may raise some questions regarding the generalizability of the findings., Conclusions: The DOTQ is able to predict treatment need as assessed by orthodontic consultants. Its incorporation in the treatment need assessment process will acknowledge patients' self-perceived impact of malocclusion., (© The Author 2016. Published by Oxford University Press on behalf of the European Orthodontic Society. All rights reserved. For permissions, please email: journals.permissions@oup.com)

The aim of the study was to investigate orthodontic treatment need and the outcome of orthodontic treatment in 15-, and 20-year-olds in Jönköping, Sweden, with special reference to residual treatment need. An offer to participate in a clinical investigation was extended to random samples of 130 15-year-olds and 130 20-year-olds. Ninety-six of the 15-year-olds (73.3%; 45 boys and 51 girls) and 82 of the 20-year-olds (62.6%; 47 males and 35 females) accepted and presented for examination The participants filled in a questionnaire and impressions were taken for study models, which were graded according to the ICON index. In all, 39 (40.6%) of the 15-year-olds and 38 (46.3%) of the 20-year-olds had undergone or were currently undergoing orthodontic treatment. Ninety-one per cent of the 15-year-olds and 84% of the 20-year-olds considered that the orthodontic treatment goals had been fully or almost fully attained. Two of the 15-year-olds and two of the 20-year-olds currently wanted orthodontic treatment. This indicates a residual treatment demand of about 2%.

During the last three decades there has been an increased influx of refugees and immigrants into Scandinavia. The overall aim of this thesis was primarily to improve our knowledge of malocclusion and orthodontic treatment need, both normative and self-perceived, in adolescents of varying geographic origin. A further aim was to determine whether any differences with respect to perception of general appearance and psychosocial well-being were related to geographic origin. Papers I and II concerned self perceived and normative orthodontic treatment need. About 500 12-13 year-old subjects, stratified into different groups: A-Sweden, B-Eastern/Southeastern Europe, C-Asia and D-other countries, answered a questionnaire and underwent clinical examination by the author. In paper III the association between the two variables in papers I and II was investigated. Paper IV was a follow up study, at 18-19 years of age, of the relationship between geographic origin and prevalence of malocclusion, self-perceived treatment need, temporomandibular symptoms and psychosocial wellbeing. In Paper V a qualitative study of 19-20-year-old subjects was conducted, to identify the strategies they had adopted to handle the issue of persisting poor dental aesthetics. The main findings were that at 12-13 years of age, immigrant subjects had a lower perceived orthodontic treatment need than subjects of Swedish background. Girls of Swedish background had the highest self-perceived treatment need, whilst girls of non-Swedish background were most concerned that fixed appliance therapy would be painful. In a few of the clinical variables measured at 12-13 years of age, the Swedish group exhibited the greatest space deficiency and irregularity in both the maxillary and mandibular anterior segments and greater overjet, compared to the Eastern/Southeastern European and Asian groups. The clinical implications were negligible. The orthodontic treatment need according to "Index of Orthodontic Treatment Need--Dental Health Component" (IOTN-DHC) grades 4 and 5, ranged from 30 to 40 per cent, without any inter-group differences. There were strong associations between subjects perceiving a need for orthodontic treatment and IOTN-DHC grades 4 and 5, anterior crossbite and avoiding smiling because they were self-conscious about their teeth. At the age of 18-19 years, the frequency of malocclusion was similar in all groups. Subjects of Asian origin had a higher self-perceived orthodontic treatment need than their Swedish counterparts and a higher frequency of headache than those of Eastern/Southeastern European origin. Psychological wellbeing was reduced in nearly one quarter of the sample, more frequently in girls than boys. No association was found between self-perceived orthodontic treatment need and psychological wellbeing. The theory "Being under the pressure of social norms" was generated in Paper V, and it can be applied to improve our understanding of young adults who have adjusted to living with poor dental aesthetics and also aid to identify those who are not as well-adjusted and would probably benefit from treatment. Undisclosed dental fear is an important barrier to acceptance of orthodontic treatment in early adolescence. Despite demographic changes due to immigration, no major change in the prevalence of malocclusion and normative orthodontic treatment need has been disclosed. This does not apply to adolescents and adults who immigrated at an older age.

Orthodontic treatment need and demand in 19-year-olds in Sweden has not previously been analysed in relation to geographic origin. The aim of this follow-up study was to examine the prevalence of self-perceived treatment need, malocclusion, earlier orthodontic treatment, self-perceived dental aesthetics and prevalence of symptoms indicative oftemporomandibular disorders in 18-19 year-olds and to analyze any differences between native born and immigrants. Body esteem and psychological wellbeing were also evaluated. The subjects, n=316, were grouped according to family origin: Group A: both parents born in Sweden (98 girls, 80 boys); Group B:the subject or at least one parent born in Eastern /South Eastern Europe (24 girls, 26 boys) and Group C: Asia (44 girls, 44 boys). Two hundered and sixty-eight participants presented for clinical examination and answered the full questionnaire, and 48 who rejected clinical examination,were interviewed by telephone using selected questions from a questionnaire. The results show that adolescents of Asian origin had a higher self-perceived treatment need than adolescents of Swedish origin. There were negligible inter-group differences with respect to frequency of malocclusion. Forty-four per cent of all participants had previously undergone orthodontic treatment, significantly more Swedish than Asian subjects. Dissatisfaction with dental aesthetics was attributed primarily to tooth colour (38 per cent) and irregular anterior teeth (34 per cent). Adolescents of Asian origin had a higher frequency of headache than those of Eastern/South Eastern European origin. Compared to boys, girls had a higher self-perceived treatment need, a higher frequency of headache and TMD and were more concerned about body appearance. Psychological wellbeing was reduced in nearly one quarter of the participants, predominantly girls: girls of Asian origin had the highest frequency. No association was found between self-perceived orthodontic treatment need and psychological wellbeing.

The aim of this study was to evaluate the association between self-perceived orthodontic treatment need and malocclusion in 12 to 13-year-old-adolescents of Swedish and immigrant background. The sample consisted of 379 students, stratified according to geographic background: both parents born in A/Sweden (n=269), B/Eastern Europe (n=56), and C/the Middle East (n=54). Registrations were based on a questionnaire, a clinical examination, radiographs, and patient records. Treatment need was classified according to the Dental Health Component (DHC) of the Index of Orthodontic Treatment Need (IOTN). Logistic regression analysis was used for comparison of the results. There was a strong association between subjects who thought that they needed an orthodontic appliance and IOTN-DHC grades 4 and 5, an anterior crossbite, those who avoided smiling because of their teeth, and those who considered their teeth to be somewhat worse or much worse than those of their peers. The self-perceived need for orthodontic treatment was significantly (P<0.05) higher in the Swedish than in the eastern European group.

The aim of this investigation was to compare Swedish and immigrant groups of 12- and 13-year-old boys and girls with respect to: (1) self-perceived need for and attitude to orthodontic treatment, (2) attitude to own teeth and general appearance, (3) behaviour pattern and psychosocial functioning, and (4) self-perceived need for orthodontic treatment in relation to psychosocial functioning. The subjects comprised 508 students, aged 12 and 13 years, living in Sweden, who were grouped according to nationality: (A) both parents born in Sweden (139 girls and 131 boys); at least one parent born in: (B) eastern Europe (27 girls and 34 boys); (C) Asia (66 girls and 61 boys) and (D) other countries (23 girls and 27 boys). Each student answered a questionnaire in the classroom. The questions concerned demographic data, self-perceived treatment need, attitude to orthodontic treatment, own teeth and general appearance, behaviour pattern and psychosocial functioning. The results showed that, on average, 20 per cent of the students had a self-perceived treatment need, more girls than boys, 24 per cent of Swedes (A), 12 per cent from eastern Europe (B), 18 per cent from Asia (C) and 14 per cent from other countries (D). Seventy-two per cent of the Swedish students were prepared to undergo fixed appliance therapy, compared with 58 per cent of immigrant students. Nine per cent of the Swedish students considered their general appearance to be less favourable compared with 7 per cent of their peers (not significant). While some differences in behaviour pattern were observed, these did not seem to influence the well-being of the subjects. The conclusion is that perceived orthodontic treatment need is lower in immigrant students than in Swedish students.

The aim of the present study was to evaluate if the majority of orthodontists in Sweden agree with the ranking of the photographs in the aesthetic component (AC) of the Index of Orthodontic Treatment Need (IOTN), and its treatment need classification. Ten separate colour photographs (originals from the AC) and two questionnaires were sent to 272 orthodontists in Sweden. Eighty-one per cent (219) returned one or both questionnaires. One hundred and ninety-four orthodontists answered the AC 'grading of dental attractiveness' and 217 the AC 'need for orthodontic treatment' (nine of the integrated questions had to be excluded because more than one alternative had been chosen). The aesthetic ranking by the orthodontists was compared with the original AC and the deviation was estimated. The results showed that the grading of photographs 2-9 varied greatly among the orthodontists, but the agreement was almost complete for photographs 1 and 10. The establishment of treatment need for each photograph had good agreement with the original index for photographs 1, 2, and 8-10, while the majority of the orthodontists considered that photographs 5 and 7 should be treated and that photograph 6 showed a borderline case. The participating Swedish orthodontists' aesthetic ranking of the photographs was: 1, 2, 3, 4, 6, 5, 7, 9, 8, and 10. Regarding treatment need, no need for treatment was set for photographs 1-4, borderline for photograph 6 and a need for treatment for photographs 5, 7-10. Further studies are needed to evaluate if laymen in Sweden make the same judgements as Swedish orthodontists.

With the purpose of examining the outcome of specialist orthodontic care on a population level (Halland, Sweden), a random sample of previously treated 19-year-olds (n=118) was clinically examined and interviewed. Thirty-three per cent of the cohort (n=1554) had received treatment, and mean treatment time was 19 months requiring 20 visits. Changes in occlusion were assessed using the PAR Index applied to dental study casts representing the pre- and post-treatment and follow-up (19 years) condition. The subjects' responses to questions addressing their past and present attitudes to dental appearance and orthodontic treatment were combined to represent "orthodontic concern", at the pre-treatment stage and at 19 years of age. A mean reduction in weighted PAR scores of 83% was observed from pre-treatment to post-treatment, whereas at follow-up, the net improvement was 69%. A significant shift in attitudes was observed, as 72% of the individuals expressed orthodontic concern pre-treatment compared to less than 10% at 19 years. The improvement obtained was similar to other studies on outcome of orthodontic treatment provided by specialist orthodontists. Compared to most PAR-studies providing information about orthodontic services, the present scheme appeared to be efficient on the assumption that duration of treatment and number of visits are expressions of costs.

The organization of the orthodontic service within the Public Dental Health Service in the southern part of the county of Halland, Sweden is described, and data for the provision of treatment are presented. The aim of this study was to examine the outcome of this service by studying the prevalence of malocclusion and residual need, as well as attitudes to treatment in previously treated and untreated individuals. Three samples of 19-year-olds were established: patients treated by specialists (n=132), patients treated by general practitioners (GP) (n=132), and untreated individuals (n=492). All samples were examined clinically, and radiographs, photographs, and study casts were obtained from the two treated groups. Attitudes to own teeth and orthodontic treatment were recorded by use of questionnaires. Deviant occlusal traits were recorded, and all the individuals were categorised according to a treatment need index. Generally, good occlusal conditions were observed in all samples. More deviant traits were observed in individuals that had been treated by GPs, and significant differences were observed for overjet, overbite, and crowding compared to the other samples. The majority of individuals belonged to the little/no treatment need index categories. Of those treated by GPs, one third belonged to the moderate (22%) or urgent (11%) need categories. About 10% reported dissatisfaction with their dental appearance, but only 2% expressed a desire for (further) orthodontic treatment.

The purpose of this series of studies was to evaluate the outcome of orthodontic care in Sweden from the professional's and the patient's perspective. In addition, a model was devised for the priority-planning of orthodontic care and for evaluating the different factors influencing the decision for orthodontic treatment. The results may be summarized as follows: Treatment Decision. Treatment desire, followed by treatment need and treatment benefit were the most important factors to consider when deciding whether or not treatment should be carried out. Regardless of the differences in resources and the structure of the free public care, a substantial proportion of the untreated 19-year-olds had malocclusions with treatment need, but they had no desire for treatment. Most of the 27-year-old individuals were satisfied with their earlier treatment decision, regardless of whether they had undergone orthodontic treatment. Dental professionals were considered to have had the greatest influence on this decision, which means that desire for treatment may be guided by the orthodontist. Individuals with malocclusions and treatment need--but who had refused proposed orthodontic treatment--were in general more discontented with their dental arrangement than other respondents, and a majority of them regretted their decision. Greater information to these individuals would have been desirable. Resources and Treatments Provided by General Practitioners or by Specialists. The sparsity of specialist resources resulted in either a greater restriction on the number necessary treatments being initiated or a greater proportion of the treatment being provided by general practitioners. In the 3 counties analysed, the treatment standard correlated well with the available resources: the greater the number of orthodontic specialists and ability to supervise the work of general practitioners and taking care of patients in need of specialist treatment, the higher the standard of treatment. Individuals treated by specialists were more contented than individuals treated by general practitioners. The measures of treatment outcome in general yielded more favourable scores for specialist treatments than for treatments provided by general practitioners, despite the specialist treatments on the average being classified as more difficult than those provided by general practitioners. Perceived treatment difficulty. About one-fourth of all treatments were classified as easy, one-fourth as moderately difficult, and one-half as difficult. The perceived treatment difficulty was associated on a group basis with the pretreatment need. The treatment investment increased and the treatment outcome became less favourable with increasing perceived difficulty. The treatment outcome was least favourable in the group where no treatment was suggested. Almost every fourth treatment was successfully carried out by mere extraction therapy. Attitudes in 27-year-olds. Orthodontic treatment was considered important by three out of four individuals, even in cases where irregularities of the teeth were small. A majority of the individuals thought that they would have been able to wear visible braces if needed, even in adult age. Methodological aspects. Studies that have used different indices to evaluate treatment outcome can only be compared with great caution. Measures with wide bases for evaluation may be more valid than measures with narrow bases. To estimate treatment outcome in terms of decrease of treatment need, the Indication Index may be recommended.

The aim of the present investigation was to determine the reasons for lack of patient co-operation and premature termination of orthodontic treatment. Over a period of 10 years files at the School of Dentistry, Huddinge, Sweden, showed that 80 patients (4 per cent) terminated treatment prematurely. These patients were interviewed regarding their reasons for not completing treatment. Lack of motivation was the most common reason given. Insufficient information about orthodontic treatment and lack of communication between the orthodontist and patient were the basis for the reasons given. Orthodontists require more knowledge of psychology and should have some training in information communication in order to further reduce the level of discontinued treatments.