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Orthodontic treatment need of adolescents in Haida Gwaii, Canada Karim, Asef Mohammed Iqbal 2013

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ORTHODONTIC TREATMENT NEED OF ADOLESCENTS IN HAIDA GWAII, CANADA  by Asef Mohammed Iqbal Karim D.M.D., The University of British Columbia, 1999 M.P.H, Boston University, 2008  A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE in THE FACULTY OF GRADUATE STUDIES (CRANIOFACIAL SCIENCE) THE UNIVERSITY OF BRITISH COLUMBIA (Vancouver) April 2013 © Asef Mohammed Iqbal Karim, 2013  Abstract Introduction: The aims of the cross-sectional study were to determine the prevalence of malocclusion and orthodontic treatment need according to the Index of Complexity, Outcome, and Need (ICON) among schoolchildren of the Aboriginal Island Community of Haida Gwaii in Northwestern British Columbia, Canada.  Methods: Out of 535 schoolchildren, 215 (90 boys and 125 girls) agreed to participate in the clinical examination. An examiner, trained in occlusal indices, assessed orthodontic treatment need in children employing the ICON score and the ICON complexity grade. In addition, a questionnaire was modified and used to measure the schoolchildren’s expectations of and selfperceived need for orthodontic treatment. Out of the 215 schoolchildren that were clinically examined, 192 were old enough to comprehend the questions in the questionnaire and were capable of completing the questionnaire without any assistance.  Results: The mean age (N=215) was 12.9±2.8 years. Of the examined schoolchildren, 67% have Aboriginal ancestry (at least one parent is Aboriginal). The mean ICON score was 43.5±26.2. There were no statistically significant differences in ICON scores regarding gender (t-test, P=0.207), ethnicity (t-test, paternal ethnicity P=0.886 and maternal ethnicity, P=0.389), or school (ANOVA with Post Hoc Bonferroni Adjustment P=0.317). Overall, 43.7% of the schoolchildren needed orthodontic treatment (ICON > 43). Based on the ICON complexity grade, 31% of the schoolchildren had moderate to very difficult malocclusions to treat. The schoolchildren (N=192) had high expectations that orthodontic treatment would straighten their teeth and give them a better smile. They had realistic expectations of how long orthodontic  ii  treatment would take; 61% felt that orthodontic treatment would take from one year to more than two years. However, they were unclear as to the frequency of check-ups during orthodontic treatment. Statistically significant differences were found in gender (t test, P=0.04, P=0.006); females had higher expectations than males that they needed orthodontic treatment and that orthodontic treatment would give them more confidence. Furthermore, males felt more comfortable leaving Haida Gwaii for treatment compared to females (t-test, P=0.014). Adolescents with higher ICON complexity scores (more complicated malocclusions) felt a greater need for orthodontic treatment, for extractions, that treatment would give them confidence, and that they were willing to be treated either on island or off island (One way ANOVA with Post Hoc Bonferroni Adjustment, P<0.001, 0.014, 0.002, <0.001, 0.007 respectively) compared to those with lower ICON scores.  Conclusions: There is need for orthodontic treatment among Haida Gwaii schoolchildren (43.7% of adolescents need orthodontic treatment according to their ICON scores). As 31% had moderate to very difficult malocclusions to treat, specialty orthodontic services are recommended. The adolescents’ self-perceived need for orthodontic treatment corresponded to their clinical need; i.e. schoolchildren with higher ICON complexity scores felt a greater need for orthodontic treatment than those with lower ICON complexity scores.  iii  Preface The study was approved by the University of British Columbia, Office of Research Services, and Clinical Research Ethics Board (Certificate Number: H11-02446).  iv  Table of Contents Abstract ........................................................................................................................................... ii	
   Preface............................................................................................................................................ iv	
   Table of Contents ............................................................................................................................ v	
   List of Tables ............................................................................................................................... viii	
   List of Figures ................................................................................................................................. x	
   List of Abbreviations ..................................................................................................................... xi	
   Acknowledgements ...................................................................................................................... xiii	
   Dedication .................................................................................................................................... xiv	
   Chapter 1:	
   Introduction and Literature Review ........................................................................... 1	
   1.1	
   Aboriginal Healthcare – The Past ...................................................................................... 1	
   1.2	
   Healthcare in Canada – Historical Perspective .................................................................. 2	
   1.3	
   Non-Insured Health Benefits Program (NIHB) ................................................................. 3	
   1.4	
   NIHB Expenditures – National Figures ............................................................................. 4	
   1.5	
   NIHB Expenditures – Regional Figures ............................................................................ 5	
   1.6	
   Dental Expenditures in the NIHB Program ....................................................................... 6	
   1.7	
   Orthodontic Policy in the NIHB Program ......................................................................... 7	
   1.8	
   Payment Structure for Comprehensive Orthodontic Treatment through NIHB ................ 8	
   1.9	
   Evolution of First Nations Healthcare ............................................................................... 9	
   1.10	
   Malocclusion Research in Canada ................................................................................. 10	
   v  1.11	
   Canadian Health Measures Survey – National Malocclusion Statistics ........................ 12	
   1.12	
   Malocclusion in Canadian Aboriginals .......................................................................... 12	
   1.13	
   Island Community of Haida Gwaii ................................................................................ 13	
   1.14	
   Orthodontics in Haida Gwaii ......................................................................................... 17	
   1.15	
   Malocclusion Indices ..................................................................................................... 17	
   1.15.1	
   Features of a Malocclusion Index ........................................................................... 17	
   1.15.2	
   Classification of Malocclusion Indices ................................................................... 18	
   1.15.3	
   Global Malocclusion Database ............................................................................... 24	
   Chapter 2:	
   Aims of the Study..................................................................................................... 26	
   2.1	
   Aims and Conceptual Framework ................................................................................... 26	
   2.2	
   Implication ....................................................................................................................... 26	
   Chapter 3:	
   Material and Methods .............................................................................................. 27	
   3.1	
   Memorandum of Understanding and Ethics Approval .................................................... 27	
   3.2	
   Study Population .............................................................................................................. 27	
   3.3	
   Clinical Examination – Index of Complexity, Outcome, and Need ................................ 28	
   3.4	
   Questionnaire About Orthodontic Treatment Expectations ............................................. 30	
   3.5	
   Statistical Analyses .......................................................................................................... 32	
   Chapter 4:	
   Results ...................................................................................................................... 35	
   4.1	
   Orthodontic Treatment Need ........................................................................................... 35	
   4.2	
   Orthodontic Treatment Complexity ................................................................................. 36	
   vi  4.3	
   Expectations About Orthodontic Treatment .................................................................... 36	
   4.4	
   ICON Complexity Scores and Expectations About Orthodontic Treatment ................... 38	
   Chapter 5:	
   Discussion ................................................................................................................ 59	
   5.1	
   Orthodontic Treatment Needs of Haida Gwaii Adolescents............................................ 59	
   5.2	
   Expectations of Orthodontic Treatment ........................................................................... 63	
   5.3	
   Canadian Malocclusion Research - Looking Ahead, Future Directions.......................... 71	
   5.4	
   Options for Orthodontic Care in Haida Gwaii ................................................................. 72	
   5.4.1	
   Option 1: Orthodontist Establishes Private Practice in Haida Gwaii ...................... 72	
   5.4.2	
   Option 2: Haida Gwaii Residents Go Off Island for Orthodontic Care ................... 74	
   5.4.3	
   Option 3: Graduate Orthodontic Residents From UBC Do Clinical Rotation in Haida Gwaii as Part of Their Residency. .............................................................................. 76	
   5.5	
   Conclusions ...................................................................................................................... 82	
   References ..................................................................................................................................... 83	
   Appendices.................................................................................................................................... 89	
   Appendix A - Poster for Recruitment ....................................................................................... 89	
   Appendix B - Orthodontic Clinical Examination Form ............................................................ 90	
   Appendix C - Questionnaire for Subjects About Orthodontic Treatment Including Braces (Treatment to Straighten Teeth) ................................................................................................ 94	
    vii  List of Tables Table 1. Malocclusion Indices Used for Occlusal Classification and Epidemiology/Data Collection ...................................................................................................................... 20	
   Table 2. Malocclusion Indices Used to Determine Orthodontic Treatment Need ....................... 21	
   Table 3. Malocclusion Indices Used to Evaluate Orthodontic Treatment Success ..................... 22	
   Table 4. Number of Students Who Participated in the Clinical Orthodontic Examination ......... 33	
   Table 5. Age of Schoolchildren Who Participated in the Orthodontic Treatment Questionnaire ................................................................................................................ 34	
   Table 6. Age Groups of Schoolchildren Who Participated in the Orthodontic Treatment Questionnaire ................................................................................................................ 34	
   Table 7. Orthodontic Treatment Need Relative to Age as Assessed by the Index of Complexity, Outcome, and Need .................................................................................. 40	
   Table 8. Orthodontic Treatment Need Relative to Schools as Assessed by the Index of Complexity, Outcome, and Need .................................................................................. 42	
   Table 9. Orthodontic Treatment Need Relative to Aboriginal Ancestry as Assessed by the Index of Complexity, Outcome, and Need ................................................................... 45	
   Table 10. Orthodontic Treatment Need Relative to Parental Ancestry as Assessed by the Index of Complexity, Outcome, and Need ................................................................... 47	
   Table 11. Assessment of Orthodontic Treatment Complexity According to the Index of Complexity, Outcome, and Need .................................................................................. 47	
   Table 12. Orthodontic Treatment Complexity Relative to Gender as Assessed by the Index of Complexity, Outcome, and Need .................................................................................. 48	
   Table 13. Schoolchildren's Responses to Orthodontic Treatment Questionnaire (N=192) ......... 51	
    viii  Table 14. Schoolchildren's Expectations of the Duration of Orthodontic Treatment .................. 52	
   Table 15. Schoolchildren's Expectations of the Frequency of Orthodontic Check-Ups ............. 53	
   Table 16. Comparison Between Male and Female Schoolchildren's Responses to Questionnaire ................................................................................................................ 54	
   Table 17. Comparison of Schoolchildren's Responses to the Questionnaire by Age Group ....... 55	
   Table 18. Schoolchildren's Responses to "What Kind of Treatment do You Think You Will Get? ............................................................................................................................... 57	
   Table 19. Schoolchildren's Responses to Questionnaire Grouped by Clinical ICON Complexity Scores ........................................................................................................ 58	
   Table 20. Travel Cost for Haida Gwaii Residents Receiving Orthodontic Treatment OffIsland ............................................................................................................................. 74	
   Table 21. Travel Savings for Health Canada with UBC Delivering Orthodontic Services ......... 77	
    ix  List of Figures Figure 1. National NIHB Expenditures for 2010/2011 .................................................................. 5	
   Figure 2. NIHB Expenditures for British Columbia 2010/2011 .................................................... 6	
   Figure 3. Islands of Haida Gwaii ................................................................................................. 13	
   Figure 4. Graham and Moresby Islands of Haida Gwaii ............................................................. 14	
   Figure 5. Communities of Haida Gwaii ....................................................................................... 15	
   Figure 6. Orthodontic Treatment Need ICON Scores for Male and Female Adolescents in Haida Gwaii ............................................................................................................................................. 41	
   Figure 7. ICON Scores for Elementary and High Schools .......................................................... 43	
   Figure 8. ICON Scores for Each Elementary and High School ................................................... 44	
   Figure 9. Comparing ICON Scores Between Adolescents With Aboriginal and Non-Aboriginal Mothers ......................................................................................................................................... 46	
   Figure 10. Frequency of ICON Complexity Scores..................................................................... 49	
   Figure 11. Frequency of ICON Complexity Scores According to Gender .................................. 50	
   Figure 12. Duration of Orthodontic Treatment (%) ..................................................................... 52	
   Figure 13. Orthodontic Delivery Model for Haida Gwaii ........................................................... 80	
    x  List of Abbreviations BC  British Columbia  CAPP  Country, Area, Profile Program  CHA  Canada Health Act  CHMS  Canadian Health Measures Survey  COHS  Canadian Oral Health Strategy  DAI  Dental Aesthetic Index  DHC  Dental Health Component  DMFT  Decayed, Missing, Filled, Teeth  FNHA  First Nations Health Authority  FNHC  First Nations Health Council  FNHDA  First Nations Health Directors Association  FNIHB  First Nations and Inuit Health Branch  FNOHS  First Nations Oral Health Survey  GPR  General Practice Residency  ICON  Index of Complexity, Outcome, and Need  IHP  Indian Health Policy  IOTN  Index of Orthodontic Treatment Need  NIHB  Non-Insured Health Benefits  OI  Occlusal Index  ORC  Orthodontic Review Centre  PAR  Peer Assessment Review  TCFNH  Tripartite Committee on First Nation’s Health  xi  TPI  Treatment Priority Index  UBC  University of British Columbia  WHO  World Health Organization  xii  Acknowledgements I am grateful to Dr. Edwin H. K. Yen and Dr. David Kennedy for this great opportunity to learn and grow as a professional by pursuing this Master’s Degree in Orthodontics. I thank Professor E.H.K. Yen for being my Research Supervisor and for allowing me to explore and ask questions on this journey. Thank you for encouraging me to present my results at the IADR Congress in Helsinki, it was a highlight for me. Dr. Jolanta Aleksejuniene, thank you for being my Co-Supervisor. Your insight and expertise have made this project a source of professional pride. I would like to thank Dr. Mario Brondani and Dr. Arminee Kazanjian for their guidance on my Supervisory Committee and for encouraging me to think outside ‘the orthodontic box’. Dr. Christopher Zed, Dr. Debbie Fonseca, Kimi Evans and Dr. Jim Rogers, thank you for your support and belief that orthodontic treatment in Haida Gwaii is a worthwhile endeavor. I am also grateful to the Haida Bands and Band Councils in Skidegate and Old Masset, to Lauren Brown, Michelle Condrotte Brown, and to all the schools for welcoming us into their communities. A heartfelt thanks Dr. Seema Basati for administration in Haida Gwaii and to Goldie Swanson in Massett for making me feel like family. Chandra Kobierski, my ‘dental sista’ and friend, thanks for making me laugh. Your comments “Dontcha luv Orthodontia” and “Hey cephlopheliac….wick*whack* give me some slack jack…let your jaw bone slide” will forever keep me amused. Dr. Ben Pliska, your energy and enthusiasm remind me how important it is to follow your heart in what you do. Thanks for this. Dr. Melanie Mattson and Dr. Reza Aran, I will remember with great fondness our joys, endless hours of lit review, and, of course, travels! Mahalo for everything! Here’s to the future!  xiii  Dedication To my family: Mom and Dad, thank you for your unconditional love and support and for giving me the strength and conviction to pursue my dreams. Raana, my sister, thanks for encouraging me to “go for it”. I am privileged and lucky to be your baby bro. Izzy and Faraaz, my ‘big guy’ and ‘little man’, it has been fun taking backpacks to school together. May your future be bright and may you always be happy as you discover your paths in life. Remember, life is what you make it boys! Kiran, my love, my life, thank you for always being there and knowing me better than myself. With you beside me, I feel like I can do anything. Truly, Madly, Deeply, I love you. I can’t wait to spend the rest of my life with you, our boys and the wee little one who will arrive just in time for graduation! You have my heart and my future, so take my hand and Chalo Dildar Chalo, Chand Key Paar Chalo.  xiv  Chapter 1:  1.1  Introduction and Literature Review  Aboriginal Healthcare – The Past With respect to healthcare coverage for First Nations or Aboriginal people, there is  only one written document or treaty that defines the responsibilities of the federal government: Treaty number six.(1) This treaty was signed by Canada and the Cree of Central Alberta and Saskatchewan in 1876; it forms the basis of the claims to health care as a right and states that: “a medicine chest shall be kept at the house of each ‘First Nations’ agent for the use and benefit of the ‘First Nations’ people’ by the direction of the agent”.(1) In 1979, the Indian Health Policy (IHP) detailed the federal government position on Aboriginal healthcare.(2) The IHP was based on three pillars: community development, the traditional relationship of the Indian people to the federal government, and the Canadian Health system.(2) Firstly, the IHP encouraged socioeconomic, cultural, and spiritual development; furthermore, it aimed to ensure that community members achieve a state of overall well-being. Secondly, the federal government advocated the interests of Aboriginal communities by “encouraging their greater involvement in the planning, budgeting, and delivery of health programs”.(2) Thirdly, the IHP recognized the complex nature of healthcare delivery involving federal, provincial, and municipal government partners, as well as Indian Bands and the private sector.(2) The historical Aboriginal position on health care is that: 1) The federal government is responsible for Aboriginal health services, 2) Aboriginal people wish only to deal with the federal government, and 3) Aboriginal people regard Treaty number six and following treaties as binding. (1)  1  1.2  Healthcare in Canada – Historical Perspective Saskatchewan was the first province in 1947 that established public universal  hospital insurance.(3) By 1957, the federal government passed legislation to share in the cost of provincial hospital insurance plans.(3) By 1961, all ten provinces and two territories had public insurance plans that covered in-hospital care.(3) In 1962, Saskatchewan started providing insurance for physician’s services outside of hospitals.(3) A decade later, all provincial and territorial plans had been extended to include physician’s services.(3) A review of Canadian health services was undertaken by Justice Emmett Hall in 1979.(3) He reported that Canadian health care ranked among the world’s best, but warned that extrabilling by doctors and user fees levied by hospitals were creating a two-tiered system that threatened the accessibility of care.(3) In response, Parliament passed the Canada Health Act (CHA) in 1984 to discourage user charges and extra-billing by physicians.(3) The Act provides for an automatic dollar-for-dollar penalty if any province allows such charges for insured health services.(3) According to Health Canada (the Federal department responsible for helping Canadians maintain and improve their health), the primary objective of the CHA is “to protect, promote, and restore the physical and mental well-being of residents of Canada and to facilitate reasonable access to health services without financial or other barriers”.(1, 3)  The five principles of the Act form the foundation of the Canadian health care system  and include: 1. Universality (all eligible residents are entitled to public health insurance coverage on uniform terms and conditions), 2. Portability (coverage for insured services must be maintained when an insured person moves or travels within Canada or travels outside the country), 3. Public administration (the health insurance plan of a province or  2  territory must be administered on a non-profit basis by a public authority, 4. Accessibility (reasonable access by insured persons to medically necessary hospital and physician services must not be impeded by financial or other barriers), and 5. Comprehensiveness (all medically necessary services provided by hospitals and doctors must be insured.(3) As such, the CHA aims to ensure that all residents of Canada, including Aboriginals, have access to necessary hospital and physician services on a prepaid basis, without direct charge at the point of service.(1-3) Beyond this federal service, provincial governments can provide further health care services to some or all of their residents, at their discretion.(1)  1.3  Non-Insured Health Benefits Program (NIHB) Today, Health Canada supports First Nations, Inuit, and Innu communities and  individuals in achieving an overall health status that is comparable to other Canadians through the Non-Insured Health Benefits (NIHB) Program of the First Nations and Inuit Health Branch (FNIHB).(4) Medically necessary benefits covered by the NIHB program include: prescription and certain over the counter drugs, medical supplies and equipment, dental care, vision care, mental health counseling, and medical transportation to health services not on reserve or in the community of residence.(4) While the Canadian population increased from 2002 to 2011 by 9.9%, the NIHB population increased by 18.2%.(4) The trend in the Aboriginal NIHB growth rate is due to Aboriginals having a higher birth rate compared to the Canadian population as a whole.(4) Moreover, new clients are probably obtaining their First Nations status.(4) As a result, the NIHB program has a higher percentage of individuals under the age of 20 (35.8%) compared to the overall Canadian population (23.0%).(4) The average age of the NIHB  3  client is 31 (male = 30 years and female = 32 years) compared to the Canadian average of 39 years.(4) To be eligible for NIHB services, an Aboriginal individual must be a Canadian resident and must have the following status: •  A registered Indian according to the Indian Act; or  •  An Inuk recognized by one of the Inuit Land Claim organizations; or  •  An infant less than one year of age, whose parent is an eligible client.(4)  Furthermore, the Aboriginal individual must fulfill the following conditions: •  Be currently registered, or eligible for registration, under a provincial or territorial health insurance plan; and  •  Is not otherwise covered under a separate agreement with federal, provincial, or territorial governments.(4) Because many of the NIHB clients live in remote or isolated areas, they are faced  with a lack of access to basic medical and dental services; consequently, these individuals face many health challenges including higher rates of caries and periodontal disease than the average Canadian.(4)  1.4  NIHB Expenditures – National Figures Figure one reveals that of the national NIHB expenditures for 2010/11 ($1,028.1  million), the highest benefit expenditures were in pharmacy costs including medical supplies and equipment ($440.8 million), medical transportation costs ($311.8 million), and dental costs ($215.8 million). (4)  4  1.5  NIHB Expenditures – Regional Figures Regionally, in 2010/11, Manitoba accounted for the highest proportion of overall  NIHB expenditure (20.2%).(4) Ontario followed at 17.0%, Saskatchewan was next at 14.9% and Alberta and British Columbia tied for fourth at 13.5%.(4) British Columbia’s NIHB expenditures followed the national trend: the highest expenditures were in pharmacy, dental, and medical transportation (Figure two).(4)  	
  Total	
  NIHB	
  Expenditures	
  2010/11	
   $1,028.1	
  Million	
   Pharmacy	
    Dental	
    Other	
  Health	
  Care	
    Premiums	
    Vision	
  Care	
    Medical	
  Transporta@on	
    30%	
    2%	
    43%	
    3%	
   1%	
    21%	
    Figure 1. National NIHB Expenditures for 2010/2011  5  NIHB	
  Expenditures	
  for	
  Bri?sh	
  Columbia	
   2010/11	
   Pharmacy	
    Dental	
    Other	
  Health	
  Care	
    Premiums	
    Vision	
  Care	
    Medical	
  Transporta@on	
    2%	
    19%	
    43%	
    13%	
   1%	
    22%	
    Figure 2. NIHB Expenditures for British Columbia 2010/2011  1.6  Dental Expenditures in the NIHB Program The NIHB Program provides financial coverage for a wide variety of dental services  to assist in optimal oral health for NIHB clients.(4) Eligible coverage exists for the following areas: diagnostic services, such as examinations and radiographs; preventive services such as scaling, polishing, fluorides and sealants; restorative services such as fillings and crowns; endodontic services such as root canal treatments; periodontal services such as scaling; removable prosthodontic services such as dentures; oral surgery services such as simple extractions; orthodontic services to correct significant irregularities in the teeth and jaws; and adjunctive services such as general anesthesia and sedation.(4) As mentioned above, in 2010/11, the total NIHB national expenditure on dental care was $215.8 million or 21.0%. (4) The highest expenditures were on restorative procedures 6  ($84.9 million); diagnostic services cost $22.4 million, preventive services cost $20.9 million, oral surgery cost $18.4 million, and removable prosthodontic services cost $11.0 million, rounding off the top five dental sub-benefits categories.(4)  1.7  Orthodontic Policy in the NIHB Program In 2002, the NIHB Program established a national Orthodontic Review Centre  (ORC) to process all requests for funding orthodontic treatment.(5) Prior to starting orthodontic treatment, predetermination or eligibility of funding for care is mandatory. In the NIHB Bulletin of 2002, the guidelines for comprehensive orthodontic treatment specifically state that NIHB will consider funding for First Nations, Inuit, and Innu clients when the following eight conditions have been met: •  The malocclusion is significantly severe and functionally handicapping;  •  All preliminary dental treatment (periodontal and restorative) has been completed;  •  The patient is caries free and has demonstrated good oral hygiene;  •  The proposed treatment is being provided at the appropriate time;  •  The client is less than 18 years old at the time the case is being submitted for assessment;  •  The patient and parent/guardian have attended the treatment conference appointment, provided consent, and are committed to the treatment plan;  •  Full orthodontics records are provided to the NIHB Program (including NIHB Orthodontic Summary Sheet and other NIHB forms);  •  The overall cost of multiple phases of treatment will not exceed the total fee of what would be charged for a malocclusion of similar severity treated in one phase.(5)  7  According to the NIHB Program funding criteria, a severe and functionally handicapping malocclusion is characterized by: dento-facial anomalies such as cleft lip and palate (which has no age restrictions) or a combination of marked skeletal discrepancy (antero-posterior, transverse, and/or vertical) and a marked dental discrepancy (anteroposterior, transverse, and/or vertical), with associated severe functional limitations for clients under eighteen years of age.(6) There are certain malocclusion conditions that the NIHB Program does not provide funding for orthodontic treatment. These include: temporomandibular disorders, nonhandicapping malocclusions (crossbite relationships without an associated significant functional shift), skeletal discrepancies with a functional pattern, severe crowing associated with compromised facial esthetics, and malocclusions associated with compromised selfesteem.(6)  1.8  Payment Structure for Comprehensive Orthodontic Treatment through NIHB Private practice dentists and orthodontists are eligible to receive payment for  orthodontic services provided to First Nations, Inuit, and Innu patients through First Canadian Health.(7) Either the professional provider can bill the NIHB Program directly for services, thereby preventing upfront charges to the patient, or can request the patient to pay and seek reimbursement from the Program. The payment structure for providers is specific and the NIHB program provides payment at the following six points: 1. At examination; 2. When initial diagnostic records are taken; 3. At initiation of treatment (reimbursement of 30% of treatment fees); 8  4. Nine months after comprehensive orthodontic treatment is initiated (reimbursement of 25% of treatment fees); 5. Fifteen months after comprehensive orthodontic treatment is initiated (reimbursement of 25% of treatment fees); 6. At completion of treatment (reimbursement of remaining 20% of treatment fees).(7)  1.9  Evolution of First Nations Healthcare An historic agreement between British Columbia First Nations, The Province of  British Columbia (BC), and the Federal Government of Canada took place in October 2011.(8) The Framework Agreement, termed the “BC Tripartite Agreement of First Nation Health Governance”, gives First Nation’s communities in BC greater control and decision making in their health and well-being.(8) Essentially, this agreement enables the federal government to transfer the planning, design, management, and delivery of First Nations health programs directly to the First Nations communities of BC.(8) The governance structure of the new Health Authority includes: 1) The First Nations Health Authority (FNHA). This organization will take responsibility for planning, managing, delivering, and funding all health programs that are currently provided to First Nations in BC through Health Canada.(8, 9) 2) The Tripartite Committee on First Nations Health (TCFNH). This organization will co-ordinate and align planning and service delivery between the First Nations Health Authority, the BC health authorities, and the BC Ministry of Health.(9)  9  3) The First Nations Health Council (FNHC). This organization will support health priorities and objectives of BC First Nations and provide leadership for implementation or tripartite responsibilities.(9) 4) The First Nations Health Directors Association (FNHDA). This organization will represent Health Directors and Managers working in BC First Nations communities and will be an advisory board in research, policy, and program planning.(9) The ultimate goal with this new governance structure is to make healthcare culturally specific and to respect and to implement the traditions and the beliefs that are valued by the First Nations. With respect to dental care, the FNHA will take over the current NIHB Program and is expected to maintain the continuity of dental health benefits and services to clients.(8) In addition, the FNHA will also provide the health benefits of the remaining NIHB categories (pharmaceuticals, vision care services, medical transportation, and medical supplies and equipment health benefits).(8) The two year transition of power from Health Canada to the FNHA is currently underway and should be completed in the late summer of 2013. This is an exciting time for First Nations in BC as they are the first Aboriginal Group in Canada to assume greater control of their own healthcare. As they venture forward and their healthcare system evolves, it will be interesting to note what, if any, changes happen to their oral health care system.  1.10  Malocclusion Research in Canada In May 2004, various stakeholders, including dental professionals, academics,  students of different dental disciplines, community organizations, government 10  organizations, and consumers met in a symposium in Toronto to develop recommendations to improve oral health in Canada.(10, 11) Key priority actions discussed for developing a national oral health strategy included: collecting data on the oral health status of Canadians, improving public awareness and attitudes toward oral health, addressing the needs of marginalized populations, and advocating the establishment of a national chief oral health officer.(11) In August 2005, after a thorough consultation process, the Federal, Provincial, and Territorial Dental Directors Group established the Canadian Oral Health Strategy (COHS).(12) The goals of this document were to: advance oral health promotion, improve the overall oral health of Canadians, improve access to oral health care services, establish a country wide standardized method of monitoring and surveillance of oral health, assure that oral health research is appropriately supported, and assure appropriate numbers, distribution and education of oral health professionals.(12) The COHS details measurable oral health objectives relating specifically to the following six categories: improving oral health status, reducing dental decay, reducing periodontal disease, reducing mortality due to oral cancer, reducing oral/dental injuries, and reducing the prevalence of acquired developmental anomalies like fluorosis.(12) There are, however, certain oral health conditions, such as the crowding or malalignment of teeth, commonly called malocclusion, that are not mentioned in the COHS; consequently, there are no national objectives or goals to address orthodontic treatment needs throughout Canada.(12) Malocclusion can lead to problems with oral function (mastication, swallowing, and speech), difficulties in jaw movement, discrimination due to facial appearance and greater risk for trauma, periodontal disease or tooth decay. Its etiology is multi-factorial and is influenced by genetic and environmental factors. (13) 11  1.11  Canadian Health Measures Survey – National Malocclusion Statistics Although the COHS document lacks strategic goals for researching and measuring  malocclusion in Canada, a recent Canadian National Health Survey conducted by Health Canada called the Canadian Health Measures Survey 2007-2009 (CHMS) included an oral health component that measured malocclusion.(14, 15) Occlusal conditions, including, crossbite, severe crowding/spacing, and excessive overbite/overjet were recorded and the prevalence of malocclusion (less than acceptable occlusion) among all 12-59 year old Canadians was 24.0% (95% CI 20.9-27.5). Malocclusion among all young adults (20-39 year olds) was 24.3% (95% CI 21.2-27.6), while it was 18.5% (95% CI 15.2-22.3) among adolescents (12-19 years old).(14)  1.12  Malocclusion in Canadian Aboriginals There are limited studies that document malocclusion in Canadian Aboriginals.  Zammit et al., in 1993, showed that 95% of the Labrador Inuit youth had some degree of malocclusion and a need for orthodontic care.(16) Harrison and Davis, in 1996, documented that First Nations adolescents in British Columbia had more crowding, Cl III dental relationships, and anterior open bites than their Caucasian counterparts.(17) In 2002, Cadman et al. compared 60 First Nations orthodontic patients to 60 non-First Nations orthodontic patients; the First Nations patients had greater pre-treatment malocclusion as evidenced by their significantly higher pre-treatment Peer Assessment Review (PAR) scores compared to the non-First Nations patients.(18) Most recently, a report on a national survey of the oral health status of the Canadian First Nations was completed in September 2012. The findings from this First Nations Oral Health Survey (FNOHS) revealed that the prevalence of malocclusion among all First 12  Nations aged 12-17 years was 48.1%, 31.2% for those aged 18-39 years, and 15.4% for adults aged 40-59 years.(19)  1.13  Island Community of Haida Gwaii Currently, British Columbia ranks 2nd provincially in the absolute numbers  (196,795) of Aboriginal people (Ontario: 242,495; Alberta: 188,365; and Manitoba: 175,395).(20) Among the Aboriginal population in British Columbia is the Island Community of Haida Gwaii, previously known as the Queen Charlotte Islands. Figure three shows that this archipelago of more than 150 islands lies off the North Coast of British Columbia and has a population (mostly Aboriginal) of around 4700.(21)  Figure 3. Islands of Haida Gwaii Haida Gwaii has two main Islands: Graham Island in the North and Morseby Island in the South as show in figure four.(21)  13  Figure 4. Graham and Moresby Islands of Haida Gwaii Spread throughout Haida Gwaii (figure five), from North to South are several communities or towns, including: Old Massett (population: 694), Masset (population: 940), Port Clements (population: 440), Tlell (population: 375), Skidegate (population: 781), Queen Charlotte (population: 948), and Sandspit (population: 402).(21) These towns are connected by highway. Sandspit, the town at the Northern tip of Moresby Island is connected to Skidegate, the furthest town South on Graham Island, by a 15 minute ferry ride. Inhabited by diverse plants and animals, Haida Gwaii has often been nicknamed ‘the Galapagos of the North’ and the Gwaii Haanas National Park Reserve is a popular destination. The Islands are connected to mainland British Columbia by daily scheduled air service from two small airports and through year round ferry service.(21)  14  Figure 5. Communities of Haida Gwaii There are two health centers in Haida Gwaii, one in the Northern town of Masset and the other in the Southern town of Skidegate.(22) There are various professionals within these health centers that provide essential services to the community, including: •  A community health nurse for all immunizations and other medical duties  •  A home care nurse and long term care assistant who provide support and home visits with the community elders and people who have injured themselves and require support with cooking, cleaning, bathing, etc.  •  A maternal family health coordinator  •  A family support worker  •  A midwife  •  A drug and alcohol counselor  •  A women’s trauma counselor  15  •  A victim support worker  •  A medical doctor who sees elderly patients at home every alternate Thursdays  •  An optometrist and audiologist who visit the health centers every 3-4 months  In addition, there is a diabetes clinic which runs regularly and promotes healthy eating with cooking and shopping classes. There is also a 3 year old and kindergarten round-up for immunizations and dental fluoride treatments and a grade 7 sexual education presentation held once a year. The health centers in Masset and Skidegate also have dental clinics. In both dental clinics there are two dental chairs; they are staffed by a receptionist and a dental assistant. Currently, there is no hygienist. Haida Gwaii residents receive regular dental care (hygiene services, preventive care, direct restorations, root canal treatments, extractions, crowns and bridges, etc.) by dental residents of the Graduate Residency Program from the Faculty of Dentistry at the University of British Columbia.(22) In addition, there are regular specialty clinics in both dental clinics involving periodontics, prosthodontics, oral surgery, oral medicine and pathology, endodontics, and pediatric care. Currently, the dental clinics in Masset and Skidegate are also coordinating Community Dental Programs to encourage ‘Active Lifestyles.’ A fitness trainer or Active Lifestyles Coach has been hired to work with the communities and the local schools to determine the community needs for active lifestyles training sessions. The goals include: coordinating physical activity days (summer – outdoors; winter – indoor gymnasium), educating on the importance of active lifestyles with a direct link to healthy bones and the prevention of oral health diseases, encouraging capacity building within the community by educating about possible careers in kinesiology and personal training, and educating around  16  healthy eating and its impact on oral health. Ultimately, a culturally sensitive active lifestyle program is to be developed in partnership with the Band Councils and the schools.  1.14  Orthodontics in Haida Gwaii At present, on island orthodontic services are not provided at the dental clinics in  Masset or Skidegate; individuals have to go off island for their orthodontic treatment. For increased access to dental care and less travel off island, Haida Gwaii residents have requested an enhancement of the dental outreach provided by UBC to include on island orthodontic care. According to records at Health Canada, during the five year period from April 1st, 2006 to March 31st, 2011, there were a total of 167 requests for diagnostic records/exams submitted to the Orthodontic Review Centre in Ottawa from Haida Gwaii. Of these 167 requests for exams/records, 144 were approved and 23 were denied. Of these 144 approved requests for exams/records, there were a total of 79 orthodontic cases submitted to the Orthodontic Review Centre for review during the April 1st 2006 to March 31st 2011 period; of these 79 cases, 54 were approved. This means that, on an annual average, eleven individuals with Haida Gwaii Aboriginal status were eligible for funding from Health Canada for orthodontic treatment. Thus, the overall approval of cases for orthodontic treatment from the point of initial examination request was 32%.  1.15  Malocclusion Indices  1.15.1 Features of a Malocclusion Index Measuring and recording malocclusion can be complicated because of several reasons. Firstly, the etiology of malocclusion is multi-factorial.(23) Secondly, there are 17  several factors that impact the severity of a malocclusion, including: skeletal features, dento-alveolar features, teeth, facial aesthetics, and functional limitations. Tang and Wei(24) and Shaw(25, 26) list the components of an ideal malocclusion index: 1. Status of the group is expressed by a single number which corresponds to a relative position on a finite scale with definite upper and lower limits 2. Sensitive 3. Index value should correspond closely with the clinical importance of the disease stage it represents 4. Index value should be amenable to statistical analysis 5. Reproducible 6. Field situation should be practical with minimal equipment and instruments 7. Examination should require minimal judgment 8. The index should be easy enough to permit the study of a large population without high financial cost or energy 9. Detect a shift in group conditions (for better or for worse) 10. Valid 1.15.2 Classification of Malocclusion Indices Historically, various surveys have been used in malocclusion research. Malocclusion indices can be categorized according to one of four research objectives involved including: 1. Occlusal classification (Angle’s Classification) (27) 2. Epidemiology and prevalence data collection (Bjork et al., FDI’s Measuring Occlusal Traits) (28, 29) 18  3. Prioritizing treatment need (Canadian Health Measures Survey Orthodontic Screening, World Health Organization’s Dental Aesthetic Index (DAI), the Treatment Priority Index (TPI), the Dental Health Component of the Index of Orthodontic Treatment Need (DHC of IOTN), the Occlusal Index (OI), the Irregularity Index (II), the Handicapping Labio-Lingual Deviations Index, the ICON) (14, 30-36) 4. Orthodontic treatment success (the PAR, the Discrepancy Index of the American Board of Orthodontics, the ICON)(36-38). Table 1 illustrates the various assessment components of malocclusion indices used for occlusal classification and epidemiology and prevalence data collection. Table 2 compares the various malocclusion indices used to determine orthodontic treatment need and Table 3 compares the malocclusion indices used to evaluate orthodontic treatment success.  19  Table 1. Malocclusion Indices Used for Occlusal Classification and Epidemiology/Data Collection Occlusal Classification, Epidemiological and Prevalence Data Collection Bjork et al. FDI’s Angle’s Epidemiology Method for Classification Registration of Measuring Occlusal Occlusion Traits Component of Orthodontic Assessment in Surveys Molar occlusion relation Molar occlusion classification Anterior crossbite Posterior crossbite Crowding Spacing Anterior openbite Posterior openbite Excess overbite Excess overjet Reverse (Mandibular) overjet Midline shift Diastema Missing teeth (incisor, canine, or premolar)  X X  X  X  X X X X X X X X X X X  X X X X X X X X X X  X  X  Tooth displacement (rotation) Defective teeth (decayed, filled, crowned)  X  Malformed teeth Transposition Cephalometrics (ANB, SN-MP, lower incisor to MP)  X X  X X  X  X  X  Impeded eruption of teeth (due to crowding, displacement, supernumerary teeth, retained deciduous teeth, and any other pathologic cause) Maxillary anterior spacing irregularity in mm  X  Mandibular anterior spacing irregularity in mm  X  Defect of cleft lip/palate Mandibular protrusion Referral for life threatening conditions (oral cancer, precancerous lesions) Pain or infection requiring immediate treatment (caries, multiple extractions) Measurement made from mouth Measurement made from study casts  X X  X  X  X  20  Table 2. Malocclusion Indices Used to Determine Orthodontic Treatment Need  Component of Orthodontic Assessment Molar occlusion relation Molar occlusion classification Anterior crossbite Posterior crossbite Crowding Spacing Anterior openbite Posterior openbite Excess overbite Excess overjet Reverse (Mandibular) overjet Midline shift Diastema Missing teeth (incisor, canine, or premolar) Tooth displacement (rotation) Defective teeth (decayed, filled, crowned) Malformed teeth Transposition Cephalometrics (ANB, SNMP, lower incisor to MP) Impeded eruption of teeth (due to crowding, displacement, supernumerary teeth, retained deciduous teeth, and any other pathologic cause) Maxillary anterior spacing irregularity in mm Mandibular anterior spacing irregularity in mm Defect of cleft lip/palate Mandibular protrusion Referral for life threatening conditions (oral cancer, precancerous lesions) Pain or infection requiring immediate treatment (caries, multiple extractions) Measurement from mouth Measurement from study casts  Orthodontic Treatment Priority Need Dental Health Component Occlusal (DHC) of Index of Irregularity Index Orthodontic Index (OI) treatment Need (IOTN)  2007 Canadian Health Measures Survey (CHMS)  WHO Dental Aesthetic Index (DAI)  Treatment Priority Index (TPI)  X  X  X  X  X  X  X X X  X  X X X X X X X  X X X  X  X X  X X  X X  X  X  X  X  X X X  X  X X  X X  X X X X X  X  X X X  Index of Complexity, Outcome, and Need (ICON) X X  X  X  Handicapping Labio-Lingual Deviations Index  X  X  X  X  X  X  X  X  X  X X  X  X X X  X  X X  X  X  X  X  X  X  X  X  X  X  X  X  X  X  X  21  Table 3. Malocclusion Indices Used to Evaluate Orthodontic Treatment Success Orthodontic Treatment Success/Evaluation Peer Assessment Rating (PAR)  Discrepancy Index (DI) American Board of Orthodontics  Index of Complexity, Outcome, and Need (ICON)  X  X  X  Component of Orthodontic Assessment Molar occlusion relation Molar occlusion classification  X  Anterior crossbite  X  Posterior crossbite  X  X  X  Crowding  X  X  X  Spacing  X  X  X  Anterior openbite  X  X  X  Posterior openbite  X  X  Excess overbite  X  X  Excess overjet  X  X  Reverse (Mandibular) overjet Midline shift  X X  X  Diastema Missing teeth (incisor, canine, or premolar)  X  Tooth displacement (rotation)  X  X  Defective teeth (decayed, filled, crowned) Malformed teeth Transposition Cephalometrics (ANB, SN-MP, lower incisor to MP) Impeded eruption of teeth (due to crowding, displacement, supernumerary teeth, retained deciduous teeth, and any other pathologic cause)  X  X  X  Maxillary anterior spacing irregularity in mm Mandibular anterior spacing irregularity in mm Defect of cleft lip/palate Mandibular protrusion Referral for life threatening conditions (oral cancer, precancerous lesions) Pain or infection requiring immediate treatment (caries, multiple extractions) Measurement from mouth Measurement from study casts  X X  X  X  22  There are several assessment components that are common to the majority (more than seven of the thirteen) of malocclusion indices mentioned. These common assessment components include: molar occlusion relation, posterior crossbite, crowding, anterior openbite, excess overbite, and excess overjet, and reverse (Mandibular) overjet. When a malocclusion index is used to determine the orthodontic treatment needs of a population, the specific assessment components are observed and recorded and then a treatment need is established. For example, in the Dental Health Component of the Index of Orthodontic Treatment Need, the various features of malocclusion are observed (including: molar occlusion classification, anterior crossbite, posterior crossbite, crowding, anterior openbite, overbite, overjet, reverse overjet, hypodontia, and cleft lip/palate defects) and a treatment need is established by grade for every surveyed individual based on the most severe occlusal feature noted (grade 1= no treatment need, grade 2 = little treatment need, grade 3 = moderate treatment need, grade 4 = great treatment need, and grade 5 = very great treatment need).(32) Ranking malocclusions in such a manner can be useful in assessing the treatment needs of a large population by determining the number of surveyed individuals that fall into each grade category. Such epidemiological research is also of value to orthodontic specialty training programs and to health administrators who plan the provision of community orthodontic treatment programs. The common indices used to assess malocclusion prevalence and the orthodontic treatment needs of populations include the IOTN, the DAI, the PAR, and the ICON. The ICON is the newer index which has gained international acceptance, and studies have reported its validity and reliability (36, 39-41); it was developed through collaboration of 97 orthodontists in 9 countries.(36) The ICON was used in the present study because it is fast and easy to use (assessing 5 traits in one minute) and can be used for both pre-treatment and 23  eventual post-treatment assessments. The ICON is unique in this regard because it has been validated for both pre-treatment and post-treatment assessment; while the IOTN and the DAI have not been validated for post-treatment assessment and the PAR has not been validated for pre-treatment assessment.(36) 1.15.3 Global Malocclusion Database Universally, there is no one single orthodontic index that is used to assess the prevalence and orthodontic treatment needs of populations. Literature review of orthodontic studies reveals various types of orthodontic indices that have been used in different regions throughout the world.(42-49) Furthermore, there is no global database that provides comparative information from all previous orthodontic studies or surveys. Global comparative data are available on other oral health conditions, such as caries, through the caries index (commonly called Decayed, Missing, Filled, Teeth or DMFT) on the World Health Organization (WHO) website called “CAPP”.(50) CAPP, the acronym for “WHO Oral Health Country/Area Profile Programme”, was established in 1995 by the WHO Collaborating Centre of Malmo, Sweden in a continuing effort to present key global oral health data.(50) For example, CAPP lists the mean DMFT values (of 12 year olds) for 188 countries and estimates the global caries burden of 2004.(51) The data on the caries index are based upon a standardized measurement and collection methodology and are useful in identifying trends in caries prevalence regionally and internationally.(50) Such data can be an instrument in developing country dental services and distribution of healthcare resources after analyzing related variables such as the geographic distribution of disease (rural versus urban) and the impact of socioeconomic status on disease prevalence and severity.(50) 24  Using a standardized approach to determine malocclusion prevalence and orthodontic treatment needs of communities is important for several reasons. Firstly, severely handicapping malocclusions that are identified can be referred for treatment. Secondly, identifying communities in need of orthodontic care could attract orthodontic practitioners who are looking to set up practices. Thirdly, publicly funded oral health care services could be directed to orthodontic programs for treatment in severe cases or in underserved communities. As well, dental universities could develop orthodontic programs involving research and services (in undergraduate and graduate programs) to underserved populations. Ultimately, objective comparative studies on the prevalence of malocclusion and orthodontic treatments needs of different groups may help to elucidate the factors that contribute to and cause malocclusions.  25  Chapter 2:  2.1  Aims of the Study  Aims and Conceptual Framework In order to plan the integration of orthodontic care into existing dental programs at  Haida Gwaii, it was essential to first determine the orthodontic treatment needs of this aboriginal population. The framework for the study included an epidemiological survey combined with a questionnaire. The primary aim of this study was to conduct a cross sectional epidemiological study on Haida Gwaii adolescents to determine the prevalence of malocclusion and orthodontic treatment needs. Secondarily, a questionnaire was conducted to determine the schoolchildren’s expectations of and self-perceived need for orthodontic treatment.  2.2  Implication The results of this study could help to strategize the on island implementation of  orthodontic services.  26  Chapter 3:  3.1  Material and Methods  Memorandum of Understanding and Ethics Approval A Memorandum of Understanding was signed by the Local Haida Gwaii Band  Leaders, the UBC Graduate Orthodontics Department, and the UBC Dental Graduate Residency Program. The study was also approved by the Clinical Research Ethics Board at UBC (Certificate Number H11-02446).  3.2  Study Population Two elementary and two high schools in Haida Gwaii were approached for census  sampling of adolescents. Letters were sent to the Principals, schoolteachers, and the parents or guardians of the children to be examined to inform them about the examination procedure, to assure them of the confidentiality of the information collected, and to seek consent for the children’s participation in both the clinical examination and the questionnaire. Posters (Appendix A) were put up in the schools and community centers. A ten dollar I-Tunes card was given to every participant. Out of 535 schoolchildren, 215 (90 boys and 125 girls) agreed to participate (40.2% response rate). Table 4 shows the number of students that participated from each school. The age range of the schoolchildren was 7-18 years. None of the participants had previous orthodontic treatment, Cleft Lip/Palate, or any other syndromes. Out of the 215 who agreed to participate, 192 (85 boys and 107 girls) completed the questionnaire. The age range of these schoolchildren was 9-18 years. Table 5 shows the age distribution of the schoolchildren.  27  In order to analyze the data for the questionnaire, 3 larger groups were constructed by combining ages 9-12 (Group 1), 13-15 (Group 2), and 16-18 (Group 3) as seen in Table 6.  3.3  Clinical Examination – Index of Complexity, Outcome, and Need The occlusal index used to assess the prevalence of malocclusion and the need for  orthodontic treatment in this adolescent population was the Index of Complexity, Outcome, and Need (ICON) (32, 36). The ICON was developed to assess orthodontic treatment need, treatment complexity, and treatment outcome.(36) The ICON scoring system evaluates five clinical traits: dental aesthetics by the Aesthetic Component of the Index of Orthodontic Treatment Need (IOTN), upper arch crowding/spacing, crossbite, incisor vertical relationship (open bite/over bite), and buccal segment (anteroposterior relationship).(36) A detailed description of the five components of the ICON and the methodology of examination that was used in this study is described below and a copy of the clinical form used for examination is listed in Appendix B.(36) 1. Dental Aesthetics (Dental Aesthetic Component of the IOTN).(36) The dentition that is to be evaluated is compared to the illustrated scale and a global attractiveness is obtained without trying to perfectly match the malocclusion to any particular picture on the scale. This scale can be used in the mixed and permanent dentition. The dentition is graded from 1 to 10 (from most attractive to least attractive). Once the score is obtained, it is multiplied by a weighting of 7.(36) 2. Crossbite.(36) A crossbite is present if the transverse relation of cusp to cusp or worse exists in the buccal segment. This includes buccal and lingual crossbites of one or more teeth, with or without mandibular displacement. Anterior teeth that are in edge to edge 28  position or in lingual occlusion are considered to be in crossbite. When there is a crossbite either in the posterior or anterior segment, a raw score of 1 is given and then it is multiplied by the weighting factor of 5. When there is no crossbite, a score of 0 is given.(36) 3.  Anterior Vertical Relationship.(36) This component includes open bite and deep bite. If both traits exist, then the highest scoring trait is scored alone. Positive overbite is measured on the deepest part of the overbite on incisor teeth and open bite is measured to the mid incisal edge of the most deviant upper tooth. Scoring protocol is given Appendix B and the raw score obtained is multiplied by 4.(36)  4.  Upper Arch Crowding/Spacing.(36) This helps to quantify the tooth to tissue discrepancy in the upper arch or identify the presence of impacted teeth in both arches. The sum of mesio-distal crown diameters is compared to the available arch circumference (mesial to the last standing tooth on each side). A ruler can be used or estimation by the eye can be done. Once the crowding/spacing is determined, the score is determined (see Appendix B) and is multiplied by the weighting of 5. Impacted teeth (unerupted) in the upper or lower arch score maximum for crowding.(36)  5.  Buccal Segment/Anterior-Posterior (AP) Relationship.(36) The scoring evaluates canine, premolar, and molar teeth. The AP cuspal relationship is scored (cusp to cusp Cl I, II, or III is given a score of 0 and any cusp relation up to but not including cusp to cusp is given 1 point, and cusp to cusp is given 2 points) and the raw scores for both sides are added together and then multiplied by the weighting of 3.(36) Once all five categories are scored and appropriately weighted, they are summed for  a total ICON score. The ICON scoring can be done on mixed dentition or permanent dentition either clinically, on study models or with intra-oral photographs. A score greater 29  than 43 indicates that orthodontic treatment is needed. The ICON categorizes how difficult or complex a malocclusion is to treat in the following ICON score categories: < 29 = easy to treat, 29-50 = mild complexity, 51-63 = moderate complexity, 64-77 = difficult to treat, and > 77 = very difficult to treat.(36) A single trained examiner (second year graduate orthodontic resident) conducted the ICON examinations. The examinations were conducted in each school in a well lit room. A simple chair was provided for participants to be seated during the ICON examination and disposable gloves, measuring probes, and tongue retractors were used for the direct examination in the knee-to-knee position. Prior to the clinical examinations in Haida Gwaii, intra-examiner reliability was conducted. A total of 35 patients from the UBC Graduate Orthodontic Clinic were examined and re-examined two weeks later (using standardized digital pre-treatment orthodontic study models and photographs) with the ICON. The Pearson-Correlation Coefficient was between 0.87-0.98 (P < 0.001) for the 5 traits being measured by ICON, indicating a high level of intra-examiner agreement i.e. reproducibility of ICON scores. No study casts, radiographs, or previous dental records of the participants were used. A Community Health Worker was paid a daily honorarium to assist in the survey.  3.4  Questionnaire About Orthodontic Treatment Expectations A questionnaire (based on Sayers and Newton’s survey)(52) was modified and used to  measure the schoolchildren’s expectations of and self-perceived need for orthodontic treatment (Appendix C). In total, thirty one questions were asked; one question was an open ended question, one question was fill in the blank, three questions included tables with options for ticking established responses, and twenty-six questions had a visual analogue 30  scale (VAS) at 10mm intervals with ‘not at all’ indicating 0 and ‘very much’ indicating 100 percent of the time. Students who completed the clinical examination were invited into a separate room to complete the questionnaire. The questionnaire and a pencil were provided. A Community Health Worker, who was paid a daily honorarium to assist in the questionnaire distribution and collection, stayed with the students while they completed the questionnaire. The questionnaire inquired about: the schoolchildren’s socio-economic status (SES), their lifestyle, when they had their last dental visit, their expectations during an initial orthodontic appointment, potential extractions or jaw surgery, problems associated with orthodontic treatment (pain, restrictions on eating or drinking), having straighter teeth and a better smile, improving chances for a good career and having more confidence, their perceived need for orthodontic treatment, how long orthodontic treatment would take, how often check-ups would be required during orthodontic treatment, and if they would choose to receive orthodontic treatment from an orthodontic professional who came to their community or if they would feel more comfortable traveling outside of Haida Gwaii for orthodontic care. In order to determine the consistency of the students’ responses, the students were asked the question “When was your last dental visit?” twice (once near the beginning of the questionnaire and once near the end of the questionnaire). Possible responses to this question included ticking one of the boxes labeled “never”, “more than 1 year ago”, “1 year ago”, or “within 1-11 months”. The Kappa statistic for the 192 schoolchildren that completed the questionnaire was 0.87 (P < 0.001) for these two questions, indicating a high level of agreement of self-reported data.  31  3.5  Statistical Analyses A power calculation suggested that the appropriate sample size for the clinical  examination should consist of 502 males and 502 females; however, this was not feasible as the total number of Haida Gwaii adolescents was 535. Data from the examinations and questionnaires at the schools were recorded on examination forms and questionnaire forms and then entered into Microsoft Excel. Data processing and analyses were carried out using the Statistical Package for Social Sciences, version 20.0 (SPSS Inc., Chicago, Illinois, USA). For the descriptive statistics, categorical variables were presented as percentages and quantitative variables as means and standard deviations. In bivariate analyses, gender and ethnicity related differences with respect to ICON scores were tested by the independent sample t-test. To compare schools, Analysis of Variance followed by Post Hoc Bonferroni adjustment was used and the complexity scores relative to gender were analyzed by the Pearson Chi-Square test.  32  Table 4. Number of Students Who Participated in the Clinical Orthodontic Examination  Total Number of  Number of Students  Students  examined (% of Total)  Tahaygen Elementary, Masset  100  37 (37)  Ska’aadgaa Naay Elementary,  173  37 (21)  George Dawson High School, Masset  110  41 (37)  Queen Charlotte High School,  152  100 (66)  535  215 (40)  School  Skidegate  Skidegate Total  33  Table 5. Age of Schoolchildren Who Completed the Orthodontic Treatment Questionnaire Age  Frequency (N)  Percent (%)  9  7  3.6  10  17  8.9  11  15  7.8  12  18  9.4  13  39  20.3  14  27  14.1  15  24  12.5  16  25  13.0  17  18  9.4  18  2  1.0  Total  192  100  Table 6. Age Groups of Schoolchildren Who Completed the Orthodontic Treatment Questionnaire Age Groups  Frequency (N)  Percent (%)  9-12  57  30.0  13-15  90  47.0  16-18  45  23.0  Total  192  100  34  Chapter 4:  4.1  Results  Orthodontic Treatment Need The mean age of the examined population (N=215) was 12.9 ± 2.8 years; for males  it was 13.5 ± 2.6 years and for females it was 12.6 ±2.9 years. Orthodontic treatment need (those who had an ICON score > 43) was found in 43.7% of the examined adolescents (N=215). The mean ICON score was 43.5 ± 26.2. Table 7 shows the mean ICON scores for the various age groups. Analysis of Variance showed no statistical significance (P=0.139) between the age groups; however, the eldest age group (16-18 year olds) had the highest ICON score. Although females tended to have lower ICON scores than males, there were no statistically significant gender related differences in ICON scores (Figure 6; independent sample t-test, P=0.207); the mean ICON score for males was 46.1 ± 26.6 and for females, the mean ICON score was 41.5 ± 25.9 (Figure 6). Table 8 reveals that elementary schoolchildren had lower ICON scores than students from high schools; however, these differences were not statistically significant. Figure 7 shows the range of ICON scores for elementary schools and high schools and figure 8 shows the range of ICON scores for each school. With respect to ethnicity, 67% of the examined adolescents were of Aboriginal ancestry (32% had at least one parent that was Aboriginal and 35% had both parents that were Aboriginal) and 33% were non-Aboriginal. Table 9 shows that adolescents with Aboriginal fathers had similar ICON scores to those with non-Aboriginal fathers. Adolescents with Aboriginal mothers had slightly higher ICON scores than those with non-Aboriginal mothers (Table 9). Figure 9 shows the range of ICON scores for 35  adolescents with Aboriginal and non-Aboriginal mothers; adolescents with Aboriginal mothers had a larger range with higher ICON scores compared to adolescents with nonAboriginal mothers. Analysis of Variance showed that there were no significant differences among adolescents having either both Aboriginal parents, one Aboriginal parent, or both non-Aboriginal parents (Table 10).  4.2  Orthodontic Treatment Complexity The grades of orthodontic complexity for the 215 adolescents are shown in Table 11.  The Pearson Chi-Square test revealed no statistically significant gender differences in complexity grades (Table 12). Figure 10 indicates that moderate to very difficult complexity grades were found for 31% of the examined adolescents and 69% had easy to mild complexity grades. Figure 11 shows the frequency of complexity grades in males and females.  4.3  Expectations About Orthodontic Treatment Average responses from the questionnaire are listed in Table 13. The schoolchildren  felt their socio-economic status (SES) was average and they described their lifestyle as being just above average. The schoolchildren had just above average expectation that their initial visit for orthodontic consultation would include a check-up and that their oral hygiene would be checked (questions 2 and 7). They felt strongly that they did not need extractions or jaw surgery (questions 9 and 10). There was high expectation that orthodontic treatment will give straight teeth (question 16) and a better smile (question 17). However, responses to questions 21 and 22 showed that the adolescents had low expectations of orthodontic treatment improving the chances for a good career and just below average expectations of 36  orthodontic treatment giving them confidence. Responses to questions 24 and 27 were similar; adolescents were indifferent about receiving orthodontic treatment by an orthodontist visiting Haida Gwaii or leaving Haida Gwaii to seek orthodontic care, respectively. The majority of schoolchildren believed that the duration of orthodontic treatment would be from one to two years (Table 14). Figure 12 reveals that 41% believed treatment would last between one to two years. The question on how often one will need to attend for a check-up during orthodontic treatment showed different responses. Table 15 shows that 26% of the schoolchildren expected checkups every four weeks; 16% expected checkups every two months and 22% did not know how often check-ups are needed during orthodontic treatment. Responses from male and female schoolchildren were compared (Table 16). Independent Sample T-tests revealed statistically significant differences between males and females in five questions (Lifestyle, 7, 22, 23, 27). Responses to the question on lifestyle revealed that males were more satisfied with their lifestyle as compared to females. Responses to question seven revealed that both males and females had high expectations of their oral hygiene being checked during an initial orthodontic check-up (t-Test, P=0.002). Responses to question twenty-two showed females compared to males had higher expectations of orthodontic treatment affecting their confidence level (t-Test, P=0.006). Females had a higher expectation that they needed to have orthodontic treatment compared to males as seen in question twenty three (t-Test, P=0.040). Question twenty seven revealed that males had just above average expectations of easily traveling outside of Haida Gwaii for orthodontic care, while females had just  37  below average expectations that they could travel easily off island for orthodontic care (tTest, P=0.014). Analysis of Variance, with Post Hoc Bonferroni adjustment revealed statistically significant differences between the various age groups in two questions (Table 17). With respect to SES, the oldest age group felt that they had the lowest SES. In the question about traveling easily out of Haida Gwaii for orthodontic treatment, the youngest age group felt most comfortable leaving Haida Gwaii for treatment, while the oldest age group had lower expectations of traveling outside of Haida Gwaii for treatment. Overall, there was a lot of variation in the responses to the one open ended question “what kind of treatment do you think you will get?” which are listed in Table 18. The most frequent responses included: “I don’t know”, “getting braces”, or leaving the space completely empty and not answering the question. Other responses included: “I have cavities, so I am getting fillings”, “I don’t need any treatment”, or “get a check-up”.  4.4  ICON Complexity Scores and Expectations About Orthodontic Treatment The schoolchildren were grouped according to their clinical ICON scores and their  responses to several questions were compared (Table 19). One-Way Analysis of Variance revealed statistical significance in several questions (9, 22, 23, 24, and 27). Responses to question 9 revealed that schoolchildren with moderate to difficult malocclusions had higher expectations of orthodontic treatment involving extractions of teeth compared to schoolchildren with easy or mildly complex malocclusions (ANOVA One Way, P=0.014) Responses to question 22 revealed that schoolchildren with moderate to difficult malocclusions had greater expectations that orthodontic treatment would give them confidence compared to schoolchildren with easy to mildly complex malocclusions 38  (ANOVA One Way, P=0.02). The responses to question 23 showed that schoolchildren with moderate to difficult malocclusions felt that they needed orthodontic treatment more than schoolchildren with easy to mildly complex malocclusions (ANOVA One Way, P<0.001). According to question 24, schoolchildren with higher ICON complexity scores felt more comfortable seeing an orthodontic professional that came on island to Haida Gwaii compared to schoolchildren with lower ICON complexity scores (ANOVA One Way, P<0.001). Schoolchildren with higher ICON complexity scores also responded (in question 27) that it is easier for them to travel outside of Haida Gwaii to get braces compared to those who had lower ICON complexity scores (ANOVA One Way, P=0.007).  39  Table 7. Orthodontic Treatment Need Relative to Age as Assessed by the Index of Complexity, Outcome, and Need Number of Students Age Group  Mean ICON Score ± Standard Deviation examined (%)  <10 y (6-10)  28 (13)  44.4 ± 25.2  10-12y  50 (23)  36.3 ± 21.9  13-15y  91(42)  44.1 ± 27.1  16-18y  46 (21)  49.4 ± 28.3  Total  215 (100)  43.5 ± 26.2  ANOVA One way P=0.158; Post Hoc Bonferroni adjustment P=0.139  40  Figure 6. Orthodontic Treatment Need ICON Scores for Male and Female Adolescents in Haida Gwaii  Independent sample t-Test, Mean ICON score for males = 46.1 ± 26.6 and females = 41.5 ± 25.9, P=0.207; circles represent outliers.  41  Table 8. Orthodontic Treatment Need Relative to Schools as Assessed by the Index of Complexity, Outcome, and Need (ICON) School  Mean ICON Score ± Standard Deviation  Tahaygen Elementary, Masset  38.4 ± 23.9  Ska’aadgaa Naay Elementary, Skidegate  41.1 ± 22.9  George Dawson High School, Masset  49.9 ± 28.1  Queen Charlotte High School, Skidegate  43.5 ± 27.2  ANOVA 1 Way P=0.243; Post Hoc Bonferroni adjustment P=0.317  42  Figure 7. ICON Scores for Elementary and High Schools  43  Figure 8. ICON Scores for Each Elementary and High School  ANOVA One Way, P=0.243; Post Hoc Bonferroni adjustment, P=0.317; circle represents an outlier.  44  Table 9. Orthodontic Treatment Need Relative to Aboriginal Ancestry as Assessed by the Index of Complexity, Outcome, and Need (ICON) Parental Ancestry  Mean ICON Score ± Standard Deviation  Paternal Aboriginal  43.7 ± 26.8  Non-Aboriginal  43.2 ± 25.6  Independent sample t test, P=0.886 Maternal Aboriginal  45.0 ± 27.9  Non-Aboriginal  41.9 ± 24.4  Independent sample t test, P=0.389  45  Figure 9. Comparing ICON Scores Between Adolescents With Aboriginal and NonAboriginal Mothers  Independent sample t test, P=.389; Mean ICON scores for children with Aboriginal Mothers= 45.0 ± 27.9; Mean ICON scores for children with Non Aboriginal Mothers= 41.9 ± 24.4;  46  Table 10. Orthodontic Treatment Need Relative to Parental Ancestry as Assessed by the Index of Complexity, Outcome, and Need (ICON) Aboriginal Ancestry  ICON Score ± Standard Deviation  Both parents Aboriginal  45.9 ± 28.3  One parent Aboriginal  40.9 ± 25.2  Both parents non-Aboriginal  43.3 ± 25.0  ANOVA One Way P=0.524; Post Hoc Bonferroni adjustment P=0.769  Table 11. Assessment of Orthodontic Treatment Complexity According to the Index of Complexity, Outcome, and Need (ICON) ICON Complexity Grade  Number of Adolescents (%)  Easy (<29)  72 (34)  Mild (29-50)  77 (35)  Moderate (51-63)  16 (7)  Difficult (64-77)  17 (8)  Very Difficult (>77)  33 (16)  All students  215 (100)  47  Table 12. Orthodontic Treatment Complexity Relative to Gender as Assessed by the Index of Complexity, Outcome, and Need (ICON) Gender  Adolescents  ICON Complexity Grade Male (N )  Female (N )  N (%)  Easy (<29)  28  44  72 (34)  Mild (29-50)  31  46  77 (35)  Moderate (51-63)  6  10  16 (7)  Difficult (64-77)  8  9  17 (8)  Very Difficult (>77)  17  16  33 (16)  Total  90  125  215 (100)  Chi-Square Test, P=0.750  48  Figure 10. Frequency of ICON Complexity Scores  Complexity	
  Score	
  (ICON)	
  N=215	
    16%	
   34%	
   8%	
    Easy	
  (<29)	
   Mild	
  (29-­‐50)	
   Moderate	
  (51-­‐63)	
    7%	
    Difficult	
  (64-­‐77)	
   Very	
  Difficult	
  (>77)	
    35%	
    49  Figure 11. Frequency of ICON Complexity Scores According to Gender  50  Table 13. Schoolchildren's Responses to Orthodontic Treatment Questionnaire (N=192) Question  Mean ± Standard Deviation*  Socio-economic Status (SES)  51.5 ± 12.9  Lifestyle  65.0 ± 18.3  1. Initial appointment (appt), braces fitted?  35.5 ± 28.9  2. Initial appt, check up?  57.3 ± 26.1  3. Initial appt, diagnosis?  45.5 ± 30.1  4. Initial appt, discussion?  42.3 ± 27.7  5. Initial appt, x-rays?  44.6 ± 31.4  6. Initial appt, impressions?  37.8 ± 27.9  7. Initial appt, OH check?  62.5 ± 25.6  9. Need extractions?  23.9 ± 28.7  10. Need jaw surgery?  11.8 ± 18.6  11. Ortho tx, gives problems?  33.8 ± 30.1  12. Braces painful?  47.7 ± 30.0  13. Ortho treatment (tx), problems eating?  57.6 ± 30.0  14. Ortho tx, limit foods/drinks?  58.2 ± 29.8  15. People’s reactions to braces  51.5 ± 25.1  16. Ortho tx, straighten teeth?  81.7 ± 22.9  17. Ortho tx, better smile?  64.5 ± 33.0  18. Ortho tx, easier to eat?  30.8 ± 24.8  19. Ortho tx, easier to speak?  31.7 ± 24.4  20. Ortho tx, cleaner teeth?  41.6 ± 31.5  21. Ortho tx, better career?  41.1 ± 29.1  22. Ortho tx, give confidence?  47.1 ± 31.2  23. Need ortho tx?  50.1 ± 32.5  24. Ortho tx in community?  53.5 ± 34.3  27. Ortho tx, travel out?  50.2 ± 33.2  *The range of the VAS scale used was from not at all (0%) to very much (100%)  51  Table 14. Schoolchildren's Expectations of the Duration of Orthodontic Treatment Duration of Treatment  Schoolchild Participant N (%)  <6 months  22 (12)  6 months - < 1 year  52 (27)  1 - < 2years  79 (41)  2 - > 3 years  39 (20)  Total  192  Figure 12. Duration of Orthodontic Treatment (%)  Adolescents	
  expecta?on	
  of	
  dura?on	
  of	
   orthodon?c	
  treatment	
    20%	
    12%	
   <	
  6	
  months	
   27%	
    6	
  months	
  -­‐	
  1	
  year	
   1	
  -­‐	
  <	
  2	
  years	
   more	
  than	
  2	
  years	
    41%	
    52  Table 15. Schoolchildren's Expectations of the Frequency of Orthodontic Follow-Ups Frequency of orthodontic follow-ups  Frequency N=192 (%)  Twice a week  5 (2.6)  Once a week  4 (2.1)  Every two weeks  16 (8.3)  Every four weeks  50 (26.0)  Every six weeks  10 (5.2)  Every two months  31 (16.1)  Every three months  17 (8.9)  Every six months  13 (6.8)  Every eight months  3 (1.6)  Do not know  43 (22.4)  Total  192 (100.0)  53  Table 16. Comparison Between Male and Female Schoolchildren’s Responses to Questionnaire Question  Males  Females  P  Mean ± SD  Mean ± SD  SES  51.3 ± 12.9  51.8 ± 13.1  0.127  Lifestyle  68.0 ± 19.3  61.8 ± 17.0  0.020  1. Initial appt, braces fitted?  33.8 ± 30.0  36.8 ± 28.1  0.469  2. Initial appt, check up?  57.8 ± 29.1  56.7 ± 23.6  0.814  3. Initial appt, diagnosis?  47.1 ± 32.3  44.1 ± 28.2  0.494  4. Initial appt, discussion?  40.1 ± 29.1  44.1 ± 26.6  0.336  5. Initial appt, x-rays?  47.0 ± 32.9  42.7 ± 30.3  0.346  6. Initial appt, impressions?  36.1 ± 29.1  39.1 ± 27.1  0.454  7. Initial appt, OH check?  68.9 ± 25.9  57.4 ± 24.2  0.002  9. Need extractions?  19.7 ± 26.2  27.2 ± 30.3  0.069  10. Need jaw surgery?  11.2 ± 20.9  12.2 ± 16.5  0.740  11. Ortho tx, gives problems?  38.3 ± 32.5  30.1 ± 27.6  0.065  12. Braces painful?  44.0 ± 32.6  50.6 ± 27.6  0.143  13. Ortho tx, problems eating?  60.9 ± 31.0  54.9 ± 29.1  0.168  14. Ortho tx, limit foods/drinks?  58.4 ± 32.4  58.1± 27.8  0.959  15. People’s reactions to braces  46.9 ± 26.8  55.2 ± 23.2  0.250  16. Ortho tx, straighten teeth?  78.8 ± 26.9  84.1± 18.9  0.124  17. Ortho tx, better smile?  60.8 ± 35.4  67.9 ± 30.8  0.145  18. Ortho tx, easier to eat?  30.6 ± 27.0  40.0 ± 23.2  0.915  19. Ortho tx, easier to speak?  29.0 ± 24.8  33.9 ± 24.1  0.166  20. Ortho tx, cleaner teeth?  38.0 ± 33.9  44.5 ± 29.4  0.165  21. Ortho tx, better career?  38.4 ± 31.3  43.2 ± 27.1  0.266  22. Ortho tx, give confidence?  40.2 ± 31.0  52.6 ± 30.5  0.006  23. Need ortho tx?  44.7 ± 32.2  54.4 ± 32.2  0.040  24. Ortho tx in community?  50.5 ± 34.2  55.9 ± 34.3  0.273  27. Ortho tx, travel out?  56.8 ± 32.9  44.9 ± 32.6  0.014  54  Table 17. Comparison of Schoolchildren's Responses to the Questionnaire by Age Group  SES  9-12 years Mean ± SD N = 57 54.0 ± 15.4  13-15 years Mean ± SD N = 90 52.0 ± 11.3  16-18 years Mean ± SD N = 45 47.0 ± 11.8  Lifestyle  67.0 ± 21.8  64.0 ±16.8  62.0 ± 15.9  0.489  1. Initial appt, braces fitted?  37.0 ± 28.7  37.0 ± 30.5  28.0 ± 24.8  0.374  2. Initial appt, check up?  56.0 ± 27.4  58.0 ± 26.4  28.0 ± 24.1  1.000  3. Initial appt, diagnosis?  49.0 ± 23.2  45.0 ± 33.8  41.0 ± 30.1  0.629  4. Initial appt, discussion?  40.0 ± 23.3  44.0 ± 29.2  41.0 ± 30.0  1.000  5. Initial appt, x-rays?  47.0 ± 30.1  41.0 ± 32.9  49.0 ± 30.0  0.706  6. Initial appt, impressions?  33.0 ± 22.1  40.0 ± 30.5  40.0 ± 29.1  0.464  7. Initial appt, OH check?  61.0 ± 26.1  62.0 ± 25.9  65.0 ± 24.7  1.000  9. Need extractions?  24.0 ± 26.7  22.0 ± 28.4  26.0 ± 32.1  1.000  10. Need jaw surgery?  11.0 ± 17.6  13.0 ± 20.0  9.0 ± 16.8  0.888  11. Ortho tx, gives problems?  43.0 ± 30.6  31.0 ± 31.0  29.0 ± 25.6  0.061  12. Braces painful?  47.0 ± 33.9  45.0 ± 29.0  53.0 ± 26.3  0.432  13. Ortho tx, problems eating?  59.0 ± 32.2  57.0 ± 28.6  58.0 ± 30.5  1.000  14. Ortho tx, limit foods/drinks?  53.0 ± 29.4  59.0 ± 30.4  63.0 ± 28.9  0.523  15. People’s reactions to braces  55.0 ± 28.9  50.0 ± 25.6  51.0 ± 18.3  0.528  16. Ortho tx, straighten teeth?  85.0 ± 18.2  78.0 ± 26.5  84.0 ± 19.4  0.505  17. Ortho tx, better smile?  62.0 ± 34.6  62.0 ± 34.2  74.0 ± 26.8  0.195  18. Ortho tx, easier to eat?  30.0 ± 26.7  30.0 ± 24.4  34.0 ± 24.3  0.982  19. Ortho tx, easier to speak?  32.0 ± 24.2  29.0 ± 24.8  36.0 ± 24.1  0.395  20. Ortho tx, cleaner teeth?  46.0 ± 31.6  37.0 ± 32.4  46.0 ± 28.7  0.379  Question  P value 0.018  55  21. Ortho tx, better career?  39.0 ± 25.5  40.0 ± 30.4  46.0 ± 30.5  0.763  22. Ortho tx, give confidence?  46.0 ± 30.0  47.0 ± 33.2  48.0 ± 30.0  1.000  23. Need ortho tx?  53.0 ± 29.9  51.0 ± 34.4  44.0 ± 31.8  0.610  24. Ortho tx in community?  54.0 ± 30.1  53.0 ± 35.8  54.0 ± 36.7  0.358  27. Ortho tx, travel out?  58.0 ± 31.2  53.0 ± 34.1  50.0 ± 29.8  0.002  Analysis of Variance One-way with Post Hoc Bonferroni adjustment  56  Table 18. Schoolchildren's Responses to "What Kind of Treatment Do You Think You Will Get? Responses  N (%)  “Getting braces” or “getting my teeth straightened”  41 (21)  Space for answer left empty – i.e. no response  41 (21)  “I don’t know”  40 (21)  “I don’t need anything” or “I don’t need any treatment”  18 (9)  “Get my teeth checked” or “Getting a check-up”  13 (7)  “Fillings”  13 (7)  “A cleaning”  12 (7)  “A discussion about braces”  3 (2)  “A retainer” or “A retainer to push my teeth”  3 (2)  “A check-up and talk about braces”  2 (1)  “Break my jaws and straighten my teeth” or “Jaw surgery”  2 (1)  “Something to fix the gap in my teeth”  1 (1)  “Exam, x-rays, moulds, cleaning, and instructions on how to brush  1 (1)  and clean my teeth “Teeth whitening”  1 (1)  “Get my bite aligned”  1 (1)  Total  192  57  Table 19. Schoolchildren's Responses to the Questionnaire Grouped by Clinical ICON Complexity Scores 	
   Questions  ICON Complexity Scores Easy < 29  Mean ± SD  Mild 29-50  Mean ± SD  ModerateDifficult 51-77  	
    P  Mean ± SD  Socioeconomic Status (SES)  52.0 ± 14.9  52.0 ± 13.3  51.0 ± 10.3  0.964  Lifestyle  66.0 ± 22.5  64.0 ± 17.1  63.0 ± 18.0  0.800  9. Need extractions?  12.0 ± 16.1  25.0 ± 28.8  33.0 ± 36.7  0.140  21. Ortho tx, better career?  31.0 ± 30.1  42.0 ± 28.9  47.0 ±26.9  0.067  22. Ortho tx, confidence?  32.0 ± 25.5  48.0 ± 31.7  59.0 ± 29.0  0.002  23. Need ortho tx?  18.2 ± 20.0  54.8 ± 30.9  70.3 ± 23.3  < 0.001  24. Ortho tx in community?  23.0 ± 26.9  60.0 ± 31.7  61.0 ± 32.5  < 0.001  27. Ortho tx, travel out?  36.0 ± 30.6  52.0 ± 32.5  61.0 ± 35.5  0.007  ANOVA One Way with Post Hoc Bonferroni adjustment  58  Chapter 5:  5.1  Discussion  Orthodontic Treatment Needs of Haida Gwaii Adolescents This is the first study to assess malocclusion in Haida Gwaii adolescents and the  study identified that these adolescents need orthodontic treatment. The prevalence of malocclusion in Haida Gwaii adolescents (43.7%) is more than double that reported in all Canadian adolescents in the CHMS (18.5%) and is just below the national average for First Nations adolescents in the FNOHS (48.1%).(14, 19) This distinct difference may be explained at least by differences in the populations studied. The CHMS had a sample of 6-19 year olds that was approximately 95% non-Aboriginal and 5% Aboriginal(14), while the present study of 7-18 year olds had 67% Aboriginals and 33% nonAboriginals. It appears that Aboriginal adolescents have a higher orthodontic treatment need (Haida Gwaii adolescents) than their counterpart non-Aboriginal Canadian adolescents (CHMS). Comparative data from the CHMS reported this; Non-Aboriginal adolescents had a malocclusion prevalence of 17.0%, while Aboriginal adolescents had a malocclusion prevalence of 43.1%.(14) Recent global studies also show a high prevalence of malocclusion in other populations; Senegalese adolescents had an orthodontic treatment need of 44.1% and Nigerian adolescents had an orthodontic treatment need of 38.1%.(53, 54) The mean ± SD ICON score for Haida Gwaii adolescents of 43.5 ± 26.2 is also comparable to these studies: the Nigerian adolescents had a mean ICON score of 39.7 ± 25.3 and the Senegalese adolescents had a mean ICON score in the range of 42.3-44.5.(53, 54) Overall, 40% of the school population in this study was examined through census sampling. Given the response rate was 40.2%, there is a possibility that the examined 59  adolescents (N=215) may not accurately reflect the orthodontic treatment needs of all adolescents in the Haida Gwaii schools (N=535). Given the limitations of a relatively small cohort size in Haida Gwaii, enhanced recruitment to include all Haida Gwaii adolescents should be considered. Another potential selection bias relates to gender distribution in the present study, as there were more girls (N=125) than boys (N=90). An explanation for the recruitment difference might be that females may be more concerned about their facial appearance and dental status than males, and consequently females were more likely to seek a checkup in anticipation of treatment. Our study results are consistent with studies conducted in Senegal (54) and Latvia (55), where no statistically significant gender differences were found when assessing orthodontic treatment need with the ICON. Although the gender difference was not statistically significant, potentially due to relatively small sample size, our results show that males tended to have higher mean ICON scores than females (46.1 versus 41.5). This difference is clinically relevant given that orthodontic cases with higher pretreatment ICON scores take longer to treat.(56, 57) Thus, adolescents with higher ICON scores should be informed that their orthodontic treatment will take longer than average compared to those with lower ICON scores. Assessing orthodontic treatment need in the larger context of overall oral health is also important. Good oral hygiene and being caries free is the foundation for good oral health and successful orthodontic treatment.(13) Some studies reported that the presence of malocclusion and orthodontic treatment need are closely related to dental caries and oral hygiene (58, 59). Gabris et al. (2006) showed that Hungarian adolescents with malocclusion had statistically significant higher caries rates using the decayed, missing, and filled permanent teeth (DMFT) index and more plaque using the visible plaque index (VPI) than 60  adolescents without malocclusion.(58) Nobile et al. (2007) showed that Italian adolescents with a higher DMFT were significantly more likely to require orthodontic treatment.(59) These studies indicate that adolescents with compromised oral hygiene and more caries consequently exhibit early loss of deciduous teeth and subsequent drifting and crowding of teeth, both potentially contributing to malocclusion.(58, 59) Although our study did not assess the prevalence of dental caries, one can look to other Canadian studies and the results of the CHMS for information. Several Canadian studies reported the high prevalence of dental caries in Aboriginal youth.(60-64) The CHMS reported that Aboriginal adolescents (6-11 years old) had a mean dmft (decayed, missing, and filled primary teeth) and DMFT of 6.62, while non-Aboriginal adolescents had a combined dfmt and DMFT mean of 2.28.(14) Thus, according to the CHMS, Aboriginal adolescents had close to three times the caries experience as non-Aboriginal adolescents. This difference in caries severity between Aboriginal and non-Aboriginal adolescents coincides with the higher prevalence of malocclusion in Aboriginal adolescents (43.1%) as compared to non-Aboriginal adolescents (17.0%) in the CHMS.(14) Based on the above information, one can question whether Haida Gwaii adolescents have high caries rates that contribute to the prevalent malocclusion (43.7%) in this population. Our results showed that 16-18 year olds had the highest mean ICON score of 49.4, whereas, the younger age groups had lower mean ICON scores (36.3-44.4). This trend of older adolescents having higher orthodontic treatment needs was also observed among the schools, where adolescents from high schools had higher ICON scores (49.9 and 43.5) than adolescents from corresponding elementary schools (38.4 and 41.3). Could compromised oral hygiene and caries leading to the loss of primary and permanent teeth be contributing factors to the mutilation of the dentition and subsequent malocclusion or 61  worsening of the malocclusion in these adolescents? Further research in the caries experience and oral hygiene of the adolescents and how these relate to malocclusion is needed to explore this question. With respect to ethnicity or parental ancestry, there were no statistically significant differences. These findings were unexpected. Based on the above discussion, one would expect adolescents with Aboriginal ancestry to have more malocclusion and higher ICON scores than adolescents with non-Aboriginal ancestry. One explanation for the lack of observed differences is the physical remoteness of the community, due to which there might be less of a difference between local Aboriginal and non-Aboriginal adolescents. The present findings show that there is a need for orthodontic treatment to be provided locally in Haida Gwaii as there is a lack of access to orthodontic services for all Haida Gwaii residents; the closest orthodontic office is a six hour ferry ride or plane trip away. In addition, Haida Gwaii residents seeking orthodontic treatment must consider the financial strain of a long-distance treatment over a long period. Moreover, adolescents may need to take time off school to travel off island and their parents or guardians who chaperone the adolescents during their orthodontic appointments may need to take time off work for the commute and possibly make arrangements for care of other children that stay on island. These difficulties as well as economic constraints may prevent residents whether of Aboriginal or non-Aboriginal ancestry from traveling off island for orthodontic treatment. As such, chances are that if an adolescent needs orthodontic care, he or she probably will not receive it, because of how physically isolated and far he or she lives from any orthodontic office. Another important consideration for the provision of orthodontic care locally in this remote community is the orthodontic treatment complexity. Approximately 67 adolescents 62  (31% of the examined adolescents) had moderate, difficult, or very difficult malocclusions to treat. This is clinically relevant as almost one out of every three adolescents had a malocclusion that requires the skills and technical expertise of an orthodontic specialist. This supports the case that the Haida Gwaii dental clinics should establish specialty orthodontic care, and not receive orthodontic services from existing general dentist residents who may not be comfortable and skilled with the diagnosis of complicated orthodontic cases and their treatment. Although there were no statistically significant gender differences in the ICON complexity scoring, males had more ‘very difficult’ malocclusions (19%) to treat than females (13%); this corresponds with the higher mean ICON scores for males (46.1) as compared to females (41.5). Consequently, males, as compared to females, may need more complicated orthodontic care that may take longer to treat.  5.2  Expectations of Orthodontic Treatment The questionnaire used in this study helps to shed light on the expectations that  Haida Gwaii adolescents have about orthodontic treatment and how these expectations are related to their normative (clinical) need for orthodontic care. The questionnaire was modified from a validated questionnaire(65) that was used by Sayers and Newton to assess adolescents’ expectations of orthodontic treatment in the United Kingdom; the questionnaire was not validated for the adolescent population in Haida Gwaii. Overall, the adolescents felt that their socioeconomic status (SES) was average as compared to other families (Table 13). Table 16 revealed that males and females had no statistically significant differences with respect to the perception of their family`s SES. Further information would be required (such as parental income figures, parental assets (home and care), academic achievement and grades, etc.) to determine the schoolchildren’s 63  actual SES; for the purposes of this study and discussion, the schoolchildren’s perception of their SES will be used. According to the responses, the SES of the adolescents matches their perceived need for orthodontic treatment (Table 13) and is similar (slightly higher) to their normative need according to the ICON examination (43.7% of examined schoolchildren needed orthodontics). Previous studies confirm that SES plays a role in an adolescent’s self-assessed need and desire for orthodontic treatment.(66-69) In particular, these studies suggest that normative orthodontic treatment need and the desire for orthodontic treatment is greater in deprived socio-economic groups.(66-69) The adolescents responded that their lifestyle was above average; males had a statistically significant higher response about their lifestyle than females (Table 16). Additional information about the factors that influence their lifestyle (such as: interest in school and grades, leisure-time activities, social relations, sexual behavior, physical hobbies, how much time is spent watching tv or doing computer work, shopping habits, amount of sleep, smoking, substance abuse, listening to music, bedtime hour, etc.) would be required for further discussion.(70-72) One might assume that in an isolated island environment males and females have traditional gender roles and because of that males have more ‘outside of the home’ activities and mobility in the community which may equate with their sense of a better lifestyle. For their initial orthodontic visit, the schoolchildren participants had the highest expectations for getting a check-up and having their oral hygiene examined (Table 13). They had lower expectations for getting braces placed, having a diagnosis, a discussion, xrays, or impressions (Table 13). Sayers and Newton’s study “Patient’s expectations of orthodontic treatment: Part 2-findings from a questionnaire survey” revealed similar findings among British adolescents; they also had lower expectations of getting braces 64  placed, having x-rays or impressions on their initial orthodontic visit. (52) In addition, the British adolescents had similar higher expectations, like Haida Gwaii adolescents, of having a check-up and their oral hygiene examined on their initial appointment.(52) The main difference between the British adolescents and the Haida Gwaii adolescents related to having a discussion about treatment at the initial orthodontic visit; British adolescents reported a high expectation for discussion whereas the Haida Gwaii adolescents reported a much lower expectation for discussion (Table 13). This difference may stem from cultural differences between patients and their health care providers. Discussions about treatment happen when there is communication between patient and their health care provider. McBain-Rigg and Veitch have noted that “non-Indigenous health providers” may lack understanding of Aboriginal values and culture and subsequently there may be poor communication between these providers and their patients.(73) Provided that Aboriginal Haida Gwaii patients receive the majority of their health care from non-Aboriginal health care providers, one can postulate that the Aboriginal patient may see himself or herself as the mere recipient of a service rather than an individual who can discuss choices pertaining to their health outcome. The adolescent participants felt that orthodontic treatment would be somewhat uncomfortable, make it harder to eat, speak, and clean teeth, and that they would have to limit certain foods or drinks. The awareness of potential risks and dietary restrictions (limiting soft drinks and sugar-containing foods that increase the acid level and the risk for caries) during orthodontic treatment may come from direct observation of classmates that are currently having orthodontic treatment.(74, 75) The schoolchildren also felt that people would not react negatively or positively to them if they were wearing braces. Having classmates that are currently wearing braces or have had orthodontic treatment completed 65  provides familiarity about orthodontic treatment and conditions them to accept wearing braces as part of their social norm.(76) Moreover, these adolescents are tapped into the social fabric of modern society (they have cell phones, listen to i-tunes on their i-pods, communicate through Facebook on their computers, and watch tv and movies just like urban schoolchildren) in which wearing braces can be cool.(77) The highest expectations from the adolescents were that orthodontic treatment will straighten their teeth and give them a better smile. This is consistent with the findings from Sayers and Newton and Mugonzibwa et al.(52, 78) Prabaken et al also found that the most important factor for orthodontic treatment among adolescents was that “I want to straighten my teeth”.(79) With respect to expectations of needing orthodontic treatment, the overall response was neither high nor low, but average. This correlates well with the normative (clinical) need for orthodontic treatment in these adolescents (prevalence of malocclusion was 43.7% according to the ICON examination). Kerosuo et al. also showed agreement between the normative and self-perceived need for orthodontic treatment among Kuwaiti high school students (rather than using the ICON, IOTN was used in this study).(80) A closer look at the gender differences in the perceived need for orthodontic treatment reveals that Haida Gwaii adolescent females had a higher perceived need for treatment than their counterpart males and this was statistically significant. This finding is consistent with other studies in which females are more concerned than males about the aesthetics of their dental appearance.(81-84) Trulsson et al. also confirm that female adolescents are more concerned about the aesthetics of their malocclusion while male adolescents are more concerned with the functional aspect.(76) Female adolescents in this study had higher expectations than male adolescents that orthodontic treatment would give them social confidence while being with others. 66  These responses correspond to the above discussion that females place more value on their dental aesthetics as a part of their overall appearance than males do. Both female and male participants had below average expectations that orthodontic treatment would impact their career chances. A four year longitudinal Scandinavian study showed similar results; only 45% of the adolescents that underwent orthodontic treatment felt that the treatment had a positive influence on their future possibilities.(85) Conversely, Shaw et al. revealed that patients felt that orthodontic treatment was related to better career opportunities.(86) For Haida Gwaii adolescents their career opportunities may be influenced more by their geographical location than by their dental aesthetics. Because they are living on a physically remote island with a small population rather than in a big city, these adolescents may feel that they have fewer job opportunities to explore as adults on island. Consequently, increased self-esteem is associated with having straighter teeth and a better smile, however, orthodontic treatment, alone, cannot correlate with improved career chances for these adolescents. Responses from the adolescents revealed that they have very low expectations of needing extractions or jaw surgery with potential orthodontic treatment. This corresponds to the ICON complexity scoring in which 16% of the clinically examined schoolchildren had very difficult malocclusions to treat. As such, the self-perceived need for extractions or jaw surgery matches the normative need for these adolescents. Of all, 39% of the surveyed schoolchildren believed that orthodontic treatment would take up to one year, 41% believed it would take between one and two years, and the remaining 20% believed that treatment would take longer than two years. This is in contrast to Sayer and Newton’s study in which 46% of surveyed adolescents felt orthodontic treatment would take up to two years, 19% felt it would take two or more years, and 35% 67  did not know how long orthodontic treatment would last.(52) Previous studies have revealed that there are many factors that contribute to the overall duration of orthodontic treatment time; these include: patient compliant factors (poor oral hygiene, missed appointments, loose bands and brackets), orthodontic technique and skill of the orthodontist and the number of operators, the severity of the initial malocclusion, whether orthognathic surgery is involved as part of the orthodontic treatment plan, whether extractions are needed to relieve crowding, whether headgear is used in conjunction or prior to the fixed orthodontic treatment, and the number of treatment phases.(87-89) From the records of 438 patients, Vig et al. reported that average treatment time was 31 months and that treatments involving extractions took longer.(90) Fink and Smith reported that the average time for fixed orthodontic treatment after observing 118 patients was 23.1 months.(87) Comparatively, Haida Gwaii adolescents have a realistic expectation of the duration of orthodontic treatment. This is clinically significant as orthodontic treatment success has been linked to the accuracy of predicting the duration of treatment time; if an orthodontic professional can give an accurate estimate of treatment duration, chances are the patient will cooperate more during treatment and will be more satisfied once treatment is completed.(91) The responses to the frequency of check-ups needed during orthodontic treatment, varied: 26% of the adolescents believed that check-ups are needed every four weeks, 16% believed every two months, 22% did not know, and there were minimal responses to ‘twice a week’, ‘once a week’, ‘every two weeks’, ‘every six weeks’, ‘every three months’, ‘every six months’, and ‘every eight months’. These varied responses reveal that only about 40% of the schoolchildren have a realistic idea of how often check-ups are needed during orthodontic treatment. Educating potential patients and parents or guardians will be  68  necessary to ensure that the adolescents do not miss their orthodontic appointments and that they successfully complete their orthodontic treatment in a timely fashion. The responses to the open ended question “what kind of treatment do you think you will get?” were variable. Only 21% of the schoolchildren responded that they felt they were going to get braces. This is much lower than their response to question 23 about needing orthodontic treatment which was marked on the middle of the VAS Scale and is lower than the normative need for orthodontic treatment (43.7% need orthodontic treatment according to the ICON examination). Equally, 21% of the adolescents responded that they did not know what kind of treatment they were going to get and 21% left the space blank and did not answer the question. Nine percent of the adolescents felt that they did not need any treatment. Other infrequent responses related to orthodontic treatment included: “getting jaw surgery”, “getting my bite aligned”, “having a check-up and talk about braces”, “having a discussion about braces”, “getting a retainer”, “having something to fix the gap in my teeth”. Other responses that weren’t directly related to having orthodontic treatment included: “getting fillings”, “having a check-up”, “having a cleaning, having an exam, xrays, moulds, cleaning, and instructions on how to brush and clean my teeth”, “and getting my teeth whitened”. Overall, the responses to the question revealed that there was confusion about what was being asked. The question was specifically designed without the word “orthodontic” in it so that the adolescents would not be ‘guided’ or ‘led’ to answers. As such, the question may have been ambiguous and may have confused respondents. Because of this uncertainty, adolescents may have looked to previous questions on the same page for direction. An improvement of the questionnaire design could involve asking the open ended question on a separate page (visually separating it from other questions). As  69  well, instead of asking “what type of treatment do you think you will get”, one could ask “what type of orthodontic treatment do you think you will get?” From the responses of the schoolchildren, it is apparent that they would equally consider receiving orthodontic treatment if an orthodontic professional came to their community or traveling out of Haida Gwaii for orthodontic treatment. They may have received positive and negative feedback from classmates that are currently receiving orthodontic care outside of Haida Gwaii and as such, they are unsure of what they would answer. These responses are unexpected; one would assume to save time and cost, it would be easier to receive treatment on island, rather than taking a trip every month or two. This may be conceivable from a parental perspective, but the questionnaire was directed to adolescents. Male adolescents felt more comfortable leaving Haida Gwaii for orthodontic treatment than female adolescents. This statistically significant difference may be due to lifestyle factors where males feel more comfortable than females leaving their home or community. To improve the study design and reliability of the questionnaire, a test-retest methodology(92, 93) could be used: having the students complete the questionnaire months before the clinical examinations and having them repeat the questionnaire after the clinical examination (then the results of the two questionnaires could be compared and evaluated for reliability). In addition to the non-response bias mentioned above (21% of students not answering the written question), selection bias (a significant number of eligible students did not participate in the clinical examination or questionnaire) may provide an incomplete view of the adolescents expectations about orthodontic treatment. Furthermore, the students may have guessed some of the answers to the questions, contributing to random measurement error. 70  Overall, there was an association between normative orthodontic treatment needs and the self-perceived need for orthodontic treatment in these adolescents. As the normative need increased (i.e. higher ICON complexity scores), the self-perceived need for treatment also increased; adolescents who had moderate to difficult malocclusions to treat felt they had greater need for orthodontic treatment and for extractions than those who had easy or mild malocclusions to treat. Moreover, they were willing to stay on island or go off island to receive treatment.  5.3  Canadian Malocclusion Research - Looking Ahead, Future Directions Orthodontics is an important discipline of dentistry, many times yielding life altering  results (functionally and aesthetically) for patients. Efforts to promote the inclusion of malocclusion research into the national oral health agenda are essential to address the comprehensive oral health needs of Canadians. The oral health component of the Canadian Health Measures Survey is an encouraging step towards gathering national statistics on malocclusion.(14) However, more research needs to be done. The following suggestions are potential strategies for a national malocclusion research platform: •  Encourage coalition of multi-disciplinary oral health care researchers and providers (including: orthodontists, public health dentists, university researchers, and government health directors) to critically evaluate the Canadian Oral Health Strategy and develop national goals for researching malocclusion and orthodontic treatment needs.  71  •  Develop specific objectives for improving oral health by reducing malocclusion (for example, in the ‘Global goals for oral health 2020’ developed by the World Health Organization and the World Dental Federation, there is a target under the craniofacial anomalies section to ‘increase early detection of seriously handicapping malocclusions and their referral by X%’)(94).  •  Use a standardized malocclusion and orthodontic treatment needs assessment survey technique throughout Canadian communities for objective comparative analysis.  •  Create a database for malocclusion prevalence and orthodontic treatment needs so Canadian health professionals can contemplate strategic orthodontic public health policy and care.  5.4  Options for Orthodontic Care in Haida Gwaii This study has revealed that adolescents in Haida Gwaii have a clinical (normative)  need and a self-perceived need for orthodontic treatment. Below are several options that explore the possibility of creating a sustainable orthodontic program in Haida Gwaii. 5.4.1  Option 1: Orthodontist Establishes Private Practice in Haida Gwaii In 2007, the dentist to population ratio in Canada was 1: 1909.(95) This is  comparable to other developed countries. The majority of dentists worked in private practice (more than 95%) and a minimum worked in public health settings (1%). BC was the province with the greatest density of dentists. There was a greater distribution of dentists in Canadian cities than in rural areas; there were approximately three times as many dentists working in urban areas than in rural areas.(95) A similar distribution trend exists for orthodontists in BC today. Currently, there are 133 licensed orthodontists in BC.(96) Thirty 72  six percent (48) of these orthodontists practice outside of the Lower Mainland (the region surrounding and including the city of Vancouver).(96) The closest orthodontic office to Haida Gwaii is in Prince Rupert, which is either a short flight away or a six hour ferry ride away. Because the population of Haida Gwaii is small (about 4700), there may not be a large enough pool of potential patients to keep an orthodontist busy in the long term if he or she were to live in Haida Gwaii and set up a full-time private practice orthodontic office in Masset or Skidegate. Alternatively, an orthodontist could set up practice in Masset or Skidegate and devote a couple of days a week in Haida Gwaii and spend the rest of the week elsewhere in BC in another practice or he or she could live outside of Haida Gwaii and set up a satellite practice in Haida Gwaii, where he or she would fly in once every four to six weeks for a couple of days to provide care. Such alternatives would require extensive planning in advance for the orthodontist and the staff. The drawback to living outside of Haida Gwaii and having a satellite orthodontic practice there is that the orthodontist would not have an opportunity to fully integrate into the local society and culture. Local residents may consider such an individual as an ‘outsider’ and may choose not to get treatment based on the sentiment that the professional is not worthy of their trust as he or she is not a member of their community. Furthermore, treatment delays might result if there is not an office that is open on a daily or weekly basis to deal with orthodontic emergencies. For example, if a patient’s bracket falls off and the patient has to wait three to five weeks to get the bracket re-bonded, the tooth may move in an unwanted direction and treatment may need to be stepped back in order to accommodate the change; ultimately, this could cause a delay in treatment.  73  5.4.2  Option 2: Haida Gwaii Residents Go Off Island for Orthodontic Care For Haida Gwaii residents (adolescent or adult) orthodontic services off island  require time off school or work (on a regular monthly basis for a long period, usually between two to three years), travel (either by plane or ferry), and potential lodging at a hotel (if there is an overnight stay involved). In addition, residents who do not have any funding provided through FNIHB must cover the cost of the orthodontic treatment in addition to all the travel expenses associated with the dental appointments off island. For those individuals who have Native status and their orthodontic diagnosis qualifies them for services, their orthodontic treatment is covered at cost by the FNIHB program. In addition, the Provincial Office for Health Canada is responsible to facilitate travel to ensure that their orthodontic treatment can be completed. While this is beneficial for the patient, relieving them of the financial responsibility of treatment and travel, this coverage places a large financial burden on Health Canada (Table 20).  Orthodontic Treatment Cost One individual  7500.00  Flight Costs Masset to Prince Rupert  Prince Rupert to Masset  450  450  Travel Cost Hotel and food Costs Hotel stay in Campbell River + food expense 1 night 155 + 40 195  Visit Cost  Total Travel Cost  Total cost per visit  Total cost per 4-6 week visit x 30 visits to finish tx  1095.00  32,850.00  Table 20. Travel Cost for Haida Gwaii Residents Receiving Orthodontic Treatment Off-Island  74  The Table above shows that the travel cost for one adolescent patient is about $32, 850.00 during a thirty month treatment. This could be doubled (if a parent or guardian was to chaperone) to a travel cost amount of approximately $67,500.00. When treatment cost is added to this ($7500.00), the total cost per adolescent patient for completing orthodontic treatment would be $73,200. Over time, patients may experience burnout from all of the trips off island and consequently, they may miss appointments. Absenteeism may delay completion of treatment. Ultimately, if compliance is poor, a patient’s treatment may be discontinued (either by the patient’s choice or by the orthodontist’s choice). Studies have shown that poor patient compliance results in treatment taking longer and can contribute to discontinuation of treatment.(87, 89, 97-99) Orthodontic emergencies (loose brackets, loose bands, loose or poking wires or other problems) may be a challenge to address quickly when seeking off island orthodontic care because of the travel distance involved off island to the orthodontic office. Such situations may create discomfort for the patient and have the potential to delay treatment. If patients choose not to complete their care, they may not fully benefit from the orthodontic treatment and their occlusion may not be stable in the long-term. For the orthodontic provider, the termination of a case earlier than expected has several implications. Firstly, it may be professionally dissatisfying to be unable to finish a case to one’s ability. Secondly, the orthodontist may have lost valuable working time due to missed appointments from one patient that could have been devoted to other patients. Thirdly, if an orthodontic provider is being reimbursed for care through the FNIHB program and the patient stops treatment, the orthodontist may lose a significant proportion of the overall treatment revenue because payment through the FNIHB program is based on a structured 75  schedule (as previously detailed), rather than on a monthly basis. For example, if a patient has an expected treatment course of 30 months and stops treatment at 25 months, the orthodontist will not be reimbursed for the last 20% of the treatment fee because the last 20% is paid from the NIHB program only when the case is fully completed and the completed records are sent in for review. As such, the orthodontist only gets reimbursed up to month 15 as described earlier in the payment structure for orthodontic services from NIHB despite having worked for 25 months .(7) 5.4.3  Option 3: Graduate Orthodontic Residents From UBC Do Clinical Rotation in  Haida Gwaii as Part of Their Residency. There are many benefits to having orthodontic residents provide orthodontic care in rotations at the Masset and Skidegate Dental Clinics as part of their graduate residency. A clinical rotation to Haida Gwaii would widen the scope of the residents’ educational experience; they would have the opportunity to travel to a remote part of BC to provide care to a community and its individuals who otherwise may find it difficult to seek orthodontic services. According to Brondani et al., such community based dental education and service allows students to “appreciate the diversity and challenges that health care providers encounter in everyday practice in different community environments”.(100) Furthermore, by providing treatment outside of the university dental clinic setting, students can improve their sense of cultural awareness and communication skills with different populations and community members and can begin to identify and understand the social and behavioral determinants underlying personal health care decisions in different communities.(101-103) Ultimately, experiences in Haida Gwaii may inspire residents to work in smaller communities rather than in large urban centres once they graduate from their orthodontic 76  residency. Partnering and collaborating with a university graduate program would help the Haida Gwaii dental clinics ensure that there is a sustainable orthodontic program with a perpetual source of professional providers for care (as long as the UBC graduate program continues to be successful and has students). In addition to increasing the access of orthodontic services for Haida Gwaii residents and broadening the scope of UBC graduate orthodontic residents, an orthodontic outreach program at Haida Gwaii would result in considerable travel expense savings for Health Canada. According to Table 21, if three residents supervised by one orthodontist were to visit Haida Gwaii over thirty visits to treat twenty patients, Health Canada could potentially save over one million dollars. Flight Costs  Hotel and food Costs  Visit Cost  Vancouver to Masset  Skidegate to Vancouver  Hotel stay in Haida Gwaii + food expense 3 night  Total cost per visit  636.00  458.00  725.00  1847.00  Total Travel Cost for one resident Total cost per 46 week visit x 30 visits to finish tx 55,410.00  Cost of 3 residents and 1 instructor over 30 visits: 221,640.00 Cost of travel expenses for 20 patients and their parents/guardians for 30 visits: 32,850 x 40 = 1,314,000.00 Potential travel savings: 1,092,360.00 Table 21. Travel Savings for Health Canada with UBC Delivering Orthodontic Services There are several logistical obstacles that will need to be overcome and issues that will need to be addressed in order to ensure that an orthodontic service program can be  77  incorporated into the dental program at Haida Gwaii. With respect to logistics, the following need to be considered: •  The costs of a bigger dental facility in both Masset and Skidegate to accommodate orthodontic treatment;  •  The capital cost of necessary orthodontic diagnosis equipment (a cephalometric and panoramic x-ray machine, a digital intra-oral scanner, Dolphin digital photo software) and instruments and sundries for orthodontic treatment.  Other considerations will include: •  Partnering with the Haida Gwaii Bands, Health Canada, and the dental clinics to develop a revenue sharing type community based dental program(104-106);  •  Supervising the graduate orthodontic residents over the course of treatment with experienced orthodontists;  •  Maintaining a consistent standard of care with the graduate orthodontic dental clinic at UBC (American Board of Orthodontic standards);  •  Coordinating schedules with the Haida Gwaii dental clinics so that other dental services are not disrupted;  •  Training appropriate staff (clinical assistant and receptionist) to assume roles in orthodontic patient care and management;  •  Collaborating with other specialties in Haida Gwaii (pediatric care, oral surgery, periodontics, general dentist resident) to ensure that orthodontic care is delivered with respect to the overall dental and general health of the patients;  •  Engaging the schools and community centres to conduct orthodontic health education and promotion; 78  •  Providing graduate residents with a positive work environment so that their experience is enriching and becomes the highlight of their residency.  Figure 13 details a potential orthodontic services delivery model for Haida Gwaii (based on Piskorowski’s model).(106) In this model, there would need to be a partnership and agreement between: the Masset and Skidegate Haida Bands, the Masset and Skidegate Dental Clinics, the UBC Graduate Orthodontics Program, and the UBC General Practice Residency Program. Specifically, the agreement between these parties would detail the term, financial commitments, partnership responsibilities, and the commitment to community services. Funding for the agreement could stem from a grant supported donor or from UBC affiliations (alumni or international collaborators). The partnership agreement should be based on a revenue sharing mechanism. According to Piskorowski, a revenue-sharing model is essential to creating a sustainable dental outreach program because it guarantees reliable funding for both maintenance and expansion.(106) In this model, revenue would be generated from several sources: •  Haida Gwaii residents who pay for their own orthodontic treatment because they don’t have any insurance plans or do not meet FNIHB qualification;  •  Haida Gwaii residents who receive funding for their orthodontic treatment through FNIHB;  •  Haida Gwaii residents who receive funding for their orthodontic treatment through private dental plans;  79  •  Health Canada (contributes a fee for each Haida Gwaii resident they save travel expenses on since the resident is staying on island for orthodontic care rather than traveling off island).  Negotiations would need to be made as to the method and amount of revenue sharing. Figure 13. Orthodontic Delivery Model for Haida Gwaii  Fortunately, the current relationship between the Haida Gwaii Bands, the Haida Gwaii Dental Centres, and UBC is a strong. The Haida Gwaii Bands and communities are  80  approachable, progressive, organized, and open minded to opportunities that have positive long term consequences for their well-being. As such, they have welcomed partnership with UBC Dentistry in the past to establish the dental clinics, facilitated this study with ease, and are excited at the chance to start an orthodontic program in their dental clinics to further enhance and increase access to oral health services to their communities. While this financial model for orthodontic care delivery is based on providing full treatment consistent with the standard of care at the UBC dental school (ideal case finishing to the American Board of Orthodontics), it is important to recognize that some orthodontic problems can be treated in younger patients (early mixed dentition) as a “Phase 1” treatment without having further complex treatment to obtain a “perfect” finished result. Studies107,108 have shown that there are several advantages of such partial treatment, including: •  Intervention at an earlier age  •  Patients that are not committed to long treatment courses can still get some treatment to address aspects of their malocclusion  •  Improvement in malocclusion (though not to a perfect result)  •  Treatment cost would be decreased for patients  •  Greater management of orthodontic problems (more patients would be treated)  •  Increased access of care to underserved populations.  As such, interceptive orthodontics can be a beneficial public health strategy to deliver costeffective care. It will be important to consider and include interceptive treatment within the scope of orthodontic treatment delivered by UBC to Haida Gwaii residents.  81  5.5  Conclusions There is a need for specialty orthodontic treatment in the Island Community of Haida  Gwaii. The adolescents’ self-perceived need for orthodontic treatment corresponds to their clinical need for orthodontic treatment as described below: 1. According to the ICON, 43.7% of adolescents needed orthodontic treatment. 2. Of all examined, 31% of the adolescents had complex malocclusions to treat (16% very difficult, 8% difficult, and 7% moderately complex). 3. Males had higher mean ICON scores than females (46.1 ± 26.6 versus 41.5 ± 25.9). 4. More males had complex malocclusions than females (19% and 13% respectively). Important Considerations: •  The schoolchildren had high expectations that orthodontic treatment would straighten their teeth and give them a better smile.  •  The schoolchildren had realistic expectations of how long orthodontic treatment would take (61% felt that orthodontic treatment would take from one year to more than two years).  •  Females had higher expectations than males that they needed orthodontic treatment and that orthodontic treatment would give them more confidence.  •  Males felt more comfortable leaving Haida Gwaii for treatment compared to females.  •  Adolescents with higher ICON complexity scores felt a greater need for orthodontic treatment, for extractions, that treatment would give them confidence, and that they were willing to be treated either on island or off compared to those with lower ICON scores.  82  References 1. 2. 3. 4. 5. 6. 7. 8.  9. 10. 11. 12. 13. 14. 15. 16. 17.  Bedford WR, Davey KW. 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Am J Orthod Dentofacial Orthop;137(1):18-25.  88  Appendices  Appendix A - Poster for Recruitment  Do you think you need your teeth straightened?  We invite you for a free dental check up as part of our study if you: § Are a high school student in Haida Gwaii The check up will include a dental examination to look at how straight your teeth are and a questionnaire for you about straightening teeth. In Old Masset, contact Michelle Brown at: michelle.brown@haidahealth.ca ; 250-626-3911 In Skidegate, contact, Lauren Brown at: Lauren@skidegatehc.ca; 250-559-7799 Old Masset and Skidegate Band Councils support this research study. This study does not provide treatment or promise any treatment. The results of this study will help to strategize an efficient expansion of existing dental services in both Old Masset and Skidegate Dental Clinics to include orthodontic treatment.  All participants will receive a $10.00 i-Tunes Card Faculty of Dentistry The University of British Columbia www.dentistry.ubc.ca  Dr. Asef Karim Graduate Orthodontics Program Faculty of Dentistry, 2199 Wesbrook Mall Vancouver, B.C., Canada V6T 1Z3 asefk@hotmail.com  89  Appendix B - Orthodontic Clinical Examination Form  (Based on ICON – Index of Complexity, Outcome, and Need)  ID  Date of Birth:________________________  Age2  You are:  Your Father is: Your Mother is:  1 2  Male Female  1 2  Aboriginal Non-Aboriginal  1 2  Aboriginal Non-Aboriginal  Gender2  F.ethn2  M.ethn2  90  IOTN Aesthetic Component The Aesthetic Component was originally described as "SCAN". Evans R and Shaw WC 1987 A preliminary evaluation of an illustrated scale for rating dental attractiveness…European Journal of Orthodontics 9:314318.  91  1. Dental Aesthetics Ranking (see photos) 1 2 3 4 5 6 7 8 9 10 Weighting  DA Score  x7  2. Crossbite (anterior, posterior, or both) Condition Crossbite present Crossbite not present Weighting  Crossbite  Score 1 0 x5  3. Anterior Vertical Relationship (incisor open bite or overbite – the larger of the 2) Condition Incisor open bite Complete bite < 1.0mm 1.1 - 2.0mm 2.1 - 4.0mm > 4.0mm Weighting Incisor over bite Up to 1/3 tooth 1/3 to 2/3 coverage 2/3 to full coverage Fully covered Weighting  Score AVR.open 0 1 2 3 4 x4 AVR.over 0 1 2 3 x4  92  4. Upper Arch Crowding / Space -Score the highest of the 2 Condition  Score  < 2mm 2.1 – 5.0mm 5.1 – 9.0mm 9.1 – 13.0mm 13.1-17.0mm > 17mm or at least an impacted tooth Weighting  0 1 2 3 4 5  Crowding  Uppercrowding  X5  Spacing  Upperspacing Up to 2mm 2.1 – 5.0mm 5.1 – 9.0mm > 9mm Weighting  0 1 2 3 x5  5. Buccal Segment A-P – add R and L segments together Condition Cusp to embrasure Cl I, II, or III Any cusp relation up to but not including cusp to cusp Cusp to cusp Weighting  6. Final Score  Buccal  Score 0 1 2 x3  Total  Add scores from 1+2+3+4+5  93  Appendix C - Questionnaire for Subjects About Orthodontic Treatment Including Braces (Treatment to Straighten Teeth) This questionnaire is to help explain your feelings about getting your teeth straightened. Read each question, and answer each question by placing a mark on the line nearest your expectation. No dental care is involved or promised as part of this study For example: Do you think you are a good cook? Not at all  Very Much  All information obtained is strictly confidential. If you have already had your teeth straightened you do not need to complete this questionnaire. ID Name Date of Birth:________________________  Age  You are:  Your Father is:  1 2  Gender  Male Female  1 2  Aboriginal Non-Aboriginal  F.ethn  1 2  Aboriginal Non-Aboriginal  M.ethn  Your Mother is:  Compared to other families, your family is: Very Poor Rich  Ses Very  Describe your everyday life: Bad  Life Perfect  94  When was your last dental visit? (Please tick the appropriate box below) 1 2 3 4  1)  Dent.visit  Never More than 1 year ago 1 year ago Within 1-11 months  At your initial appointment, do you think you will have braces fitted?  In.fit  Not at all  Very much  2) At your initial appointment, do you think you will have a check-up (examination of your teeth by a dentist)? Not at all  Very much  3) At your initial appointment, do you think you will find out why your teeth are not straight and you need dental treatment ? Not at all  In.check  In.diag  Very much In.disc  4) At your initial appointment, do you think you will have a discussion about treatment? Not at all  Very much In.xray  5) At your initial appointment, do you think you will have x-rays? Not at all  Very much  6) At your initial appointment do you think you will have moulds taken of your teeth? Not at all  In.imp Very much  7) At your initial appointment do you think you will be examined how well you brush your teeth? Not at all  In.OH  Very much  95  8) What type of treatment do you think you will get? Please explain in detail below:  O.tx  9) Do you think you will need teeth extracted (teeth taken out)?  Exo  Not at all  Very much  10) Do you think you will need jaw surgery? Not at all  Jawsurg Very much  11) Do you think braces (treatment to straighten your teeth) will give you any problems? Not at all  Problem Very much  12) Do you think having braces will be painful? Not at all  Pain Very much  13) Do you think having braces will produce problems with eating?  Problem.eat  Not at all  Very much  14) Do you think having braces will restrict what you can eat or drink? Not at all  Limit.eat Very much  15) How do you think people will react to you wearing braces? Extremely Negative  React Extremely Positive  16) Do you think having braces will straighten your teeth? Not at all  Straight Very much  17) Do you think having braces will give you a better smile? Not at all  Smile Very much  18) Do you think having braces will make it easier to eat? Not at all  Easyeat Very much  96  19) Do you think having braces will make it easier to speak?  Speak  Not at all  Very much  20) Do you think having braces will make it easier to keep your teeth clean?  Clean  Not at all  Very much  21) Do you think having braces will improve your chances of a good career?  Career  Not at all  Very much  22) Do you think having braces will give you confidence while being with others?  Conf  Not at all  Very much  23) Do you feel you need to have braces to straighten your teeth?  Need  Not at all  Desperately  24) You would get the braces if an orthodontist will come to your community.  Com  Not at all  Very much  25) How long do you expect braces will take to straighten teeth? Please specify in months:_____________________.  Time.treat  26) How often do you think you will need to attend for a check up? (please tick the appropriate box)  Checkup  1 2 3 4 5 6 7 8 9 10  Twice a week Once a week Every 2 weeks Every 4 weeks Every 6 weeks Every 2 months Every 3 months Every 6 months Every 8 months Don’t know  27) For you, travelling outside of Haida Gwaii is easy and you can get braces outside of Haida Gwaii. Not at all  Ortho.out  Very much  97  28) When was your last dental visit? (Please tick the appropriate box below) 1 2 3 4  Dent.visit2  Never More than 1 year ago 1 year ago Within 1-11 months  98  

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