Quality control of orthodontic treatment using ICON -

Index of complexity, outcome and need

Bekir Koca
The Institute of Odontology
Karolinska Institutet
!eden
uper"isor# Associate professor Lena Berglund-Stevenberg
1
Contents
1. Introduction
1. Index of Orthodontic Treatment Need (IOTN)
2. Peer Assessment Rating (PAR)
3. Index of Com!exit" Outcome and Need (ICON)
2. #ateria!s and #ethods
3. Resu!ts
4. $iscussion
5. Conc!usion
6. Ac%no&!edgement
7. References
2
Abstract
In this stud" a 'ua!it" contro! of the orthodontic treatment of 3( atients )et&een the ages of *
and 2( "ears has )een executed &ith the index of com!exit"+ outcome and need (ICON). The
atients &ere treated at ,aro!ins%a Institute+ $eartment of $enta! #edicine+ $i-ision of
Orthodontics+ )" either ost graduate students undergoing their education for orthodontic
secia!it" or trained orthodontists. The re. and ost.treatment stud" mode!s &ere assessed
&ith ICON and the scores &ere ca!i)rated )" the suer-isor.
R/012T3 0ho&ed a reduction of mean ICON.score of 41+5 oints. 66 7 of the atients had a
ost treatment grade of great imro-ement8 the remaining 23 7 had a su)stantia!
imro-ement. CONC210ION3 In this stud"+ the com!ete orthodontic treatments of 3(
atients at the ,aro!ins%a Institute &ere assessed &ith ICON+ Index of com!exit"+ outcome
and need sho&ing good treatment resu!ts. The ICON index &as eas" to !earn and use.
1. Introduction
In 0&eden+ chi!dren )et&een the ages of 3 unti! the "ear the" turn 2( are ro-ided denta!
ser-ice )" the count" counci!s. This means that a!! denta! care is free of charge for these
chi!dren inc!uding orthodontic treatment+ if the treatment need is su)stantia!!" high. The
count" counci!s in 0&eden ha-e gradua!!" mo-ed to&ards more stringent financia!
accounta)i!it" and ha-e had to hand!e economica! !imitations. This has !ead to a decreased
num)er of atients &ho get count" counci! funded orthodontic treatment e-en though the
treatment demand+ esecia!!" in !arger cities as 0toc%ho!m+ 9othen)urg and #a!mo has
increased. In 0toc%ho!m 2: 7 of the chi!dren and "oung adu!ts recei-e an orthodontic chec%
-a!id for the orthodontic treatment. $ue to the fact that more and more atients are denied
orthodontic treatment+ it is imortant that &e ha-e a s"stem in order to assess the need of
treatment so that atients &ith the greatest treatment need get treatment. ;ut it is e'ua!!"
imortant that &e ha-e a s"stem for the assessment of the atient treatment outcome+ for
atients recei-ing free treatment+ in order to contro! that the funded treatments ha-e gi-en
satisfactor" resu!ts.
The IOTN (Index of Orthodontic Treatment Need) and the 0&edish #edica! ;oard Index
(0#;I) are common!" used in 0&eden in order to assess the treatment need and choose the
3
deser-ing atients &ith great need for orthodontic treatment. A score of more than :( or
higher on IOTN index and<or a score of 3 or higher on the index of 0&edish hea!th authorities
is re'uired for orthodontic treatment funded )" the count" counci!s. The IOTN index &i!! )e
descri)ed in detai!s !ater.
The index of 0&edish hea!th authorities consist of a four grade sca!e. ;eside the occ!usa!
traits+ !imited consideration is ta%en to the atient=s desire. Patients &ith first and second
grade o)>ecti-e treatment need are denied treatment in site of the fact that a atient &ith
second grade o)>ecti-e need might ha-e a much higher su)>ecti-e need. In 0toc%ho!m the
atients &ith urgent need of orthodontic treatment recei-e a chec%. The chec% is -a!id for
treatment at the c!inic the atient chooses. If atients &ith a )order!ine need of treatment as%
for a second oinion+ this re'uest can )e granted. ?o&e-er as a recent stud" sho&s the
conformit" among orthodontists on treatment need is 'uestiona)!e. @1A
PAR (Peer Assessment Rating) index is an index rimari!" used to assess the treatment
resu!ts. IOTN together &ith PAR index ha-e turned out to )e usefu! indices for assessment of
treatment need and c!inica! 'ua!it" contro!. @2A ;ut+ for 'ua!it" contro!+ the most desira)!e and
otimum measurement too! &ou!d )e one unified index that co-ers )oth rocesses8
assessment of treatment need and assessment of treatment outcome. One such index8 Index of
Com!exit" Outcome and Need (ICON) &as de-e!oed )" Richmond and it has )een ro-en
to )e a assa)!e e'uiment. @3A
Cost.effecti-eness in hea!th care can )e defined as Bthat inter-ention indicated re!ati-e to the
resources consumed=. @5A In orthodontics+ this is of imortance to the atient+ the ractitioner+
and most imortant!" to the hea!th care ro-ider in countries such as 0&eden &here the
count" counci!s co-ers this cost for the chi!dren &ith functiona! need. ICON has ro-ed to )e
a re!ia)!e orthodontic index that can )e used in cost.effecti-eness studies. @:A ;" using this
s"stem+ cost er ICON oint reduction can a!so gi-e a comarison of effecti-eness )et&een
ractitioners.
1.1 IOTN (Index of Orthodontic Treatment Need
Index of orthodontic treatment and need (IOTN) &as de-e!oed as a resu!t of a go-ernment
initiati-e. The urose of this index &as to he! determine the !i%e!" imact of a ma!occ!usion
on an indi-idua!=s denta! hea!th and s"chosocia! &e!!.)eing. It comrises t&o e!ements8 one
denta! hea!th comonent and one aesthetic comonent.
4
1.1.1 !enta" hea"th com#onent
This &as de-e!oed from the index used )" the $enta! ;oard in 0&eden designed to ref!ect
those occ!usa! traits+ &hich cou!d affect the function and !onge-it" of the dentition. The sing!e
&orst feature of a ma!occ!usion is noted and categoriCed into one of fi-e grades ref!ecting
need for treatment.
9rade 1 D no need 9rade
2 D !itt!e need 9rade 3 D
moderate need 9rade 5 D
great need 9rade : D -er"
great need
Eo!!o&ing features are o)ser-ed consecuti-e!" and on!" the sing!e &orst feature is recorded.
#issing teeth
O-er >et
Cross )ite
$is!acement (of contact oints)
O-er )ite
1.1.2 Aesthetic com#onent
This asect of the index is meant to assess the aesthetic handica osed )" the ma!occ!usion
and thus the s"chosocia! imact uon the atient. A set of ten standard hotograhs are
graded from score 1 to 1( (figure 1). The atient=s teeth+ in occ!usion+ are -ie&ed from the
anterior asect and the aroriate score determined )" choosing the hotograh that is
thought to ose an e'ui-a!ent aesthetic handica. The scores are categoriCed according to
need for treatment3
0core 1.2 Dnone
0core 3.5 D s!ight
0core :+ 4+ or 6 D )order!ine<moderate
0core F+ *+ or 1( D definite
5
$i%ure 13 Photos used to score the Aesthetic Component
1.2 &eer Assessment 'atin% (&A'
The PAR index &as de-e!oed rimari!" to measure the success (or fai!ure) of orthodontic
treatment. It &as de-e!oed )" 0.Richmond et a!. @4A A num)er of arameters are recorded as
scores+ )efore and at the end of treatment+ using stud" mode!s. 1n!i%e the index for treatment
need+ the scores are cumu!ati-e and the features recorded and mu!ti!ied )" different num)ers
are3
Cro&ding D contact oint dis!acement in mm (G1)
;ucca! segment re!ationshi D in the anteroosterior+ -ertica!+ and
trans-ersa! !anes (G1)
O-er >et in mm (G4)
O-er )ite in mm(G2)
Center!ines+ difference from coinciding in mm (G5
6
The difference )et&een the PAR scores at the start and on com!etion of treatment can )e
ca!cu!ated+ and from this the ercentage change in PAR score+ &hich is a ref!ection of the
success of treatment+ is deri-ed. A high standard of treatment is indicated )" a mean
ercentage reduction of greater than 6( er cent. A change of 3( er cent or !ess indicates that
no arecia)!e imro-ement has )een achie-ed.
A!though IOTN (for assessing treatment need) and PAR (for assessing outcome) are )oth
re!ia)!e and -a!id indices the" ha-e some imortant !imitations3
. The -a!idation and de-e!oment of the IOTN index has )een made to assess treatment
entr" and exists as searate henomena. The PAR index assesses on!" occ!usa! trait
not regarding the aesthetic imact of the ma!occ!usion. The need to use these t&o
indices re'uires additiona! training and du!icates the effort of measuring &hat are
often simi!ar occ!usa! traits.
. 1sing the denta! hea!th comonent ($?C) and the aesthetic comonent (AC) &hen
categoriCing treatment can )e contradictor"+ &ith one comonent suggesting treatment
and the other !esser treatment need.
. The IOTN and PAR indices ha-e )een -a!idated against 1,.denta! oinion and thus
ma" not )e reresentati-e of rofessiona! oinions in other countries. @6A@FA
. The PAR index has )een criticiCed for undue !enienc" of residua! extraction sacing+
unfa-ora)!e incisor inc!inations+ and rotations @*A. Other authors ha-e found it undu!"
harsh on treatments &ith !imited aims @1(A
. PAR ta%es no account of eriodonta! destruction+ deca!cification+ root resortion+
d"namic occ!usion+ and facia! aesthetics @11A
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1.3 Index of (om#"exit) Outcome and Need (I(ON
An effort has )een made )" C.$anie!s and 0.Richmond+ to form a unified index8 ICON+ in
order to use the same measurement too! to assess treatment need and to assess treatment
outcome. @3A An internationa! ane! of *6 orthodontists from nine countries &as as%ed to
>udge a di-erse sam!e of stud" casts. This stud" consisted of 25( denta! casts for assessment
of treatment need and *F aired re.treatment and ost.treatment cases for assessment of
treatment outcome. The ractitioners ga-e each a dichotomous decision on the need for
treatment and the acceta)i!it" of the treatment outcome. Eurthermore+ the ractitioners ga-e
a >udgment+ for the re.treatment com!exit" and the ost.treatment degree of imro-ement.
The mean com!exit" and imro-ement rating &as then &or%ed out for each case. Hith he!
of 0te&ise #u!ti!e 2ogistic Regression+ a set of fi-e occ!usa! traits+ &hich &ere usefu! to
redict the ractitioners= dichotomous decisions+ &ere identified. Eurther detai! is resented in
figure 2.
$i%ure 23 The components in ICON and their weighting
8
In this ne& index+ the features of )oth the IOTN and the PAR are incororated. The scores+
mentioned )e!o&+ are mu!ti!ied )" its &eighting3
Aesthetic comonent of IOTN (I6)
1er arch cro&ding<sacing (I:)
Cross)ite (I:)
O-er)ite<Oen )ite (I5)
;ucca! segment re!ationshi (I3)
The stud" mode!s )efore and after treatment are mar%ed and scored.
The tota! sum of mar%ings for the initia! stud" mode! gi-es a retreatment score+ &hich is said
to ref!ect the need for+ and !i%e!" com!exit" of+ the treatment re'uired. A score of more than
53 indicates a demonstra)!e need for treatment. The retreatment scores can )e graded in
different !e-e!s of com!exit" as fo!!o&ed3
/as" J 2*
#i!d 2* to :(
#oderate :1 to 43
$ifficu!t 45 to 66
Ker" difficu!t L 66
Erom the stud" mode! ta%en after the end of the treatment+ the index is scored again and if the
summar" score is !ess than 31 the outcome is acceta)!e. /-en here+ the imro-ement grade
can )e !e-e!ed )" using the e'uation )e!o&3
Imro-ement grade M re.treatment score D (5 I ost.treatment score)
The imro-ement grades are as fo!!o&ed3
9reat!" imro-ed L .1
0u)stantia!!" imro-ed .2: to .1
#oderate!" imro-ed .:3 to .24
#inima!!" imro-ed .F: to .:5
Not imro-ed or &orse J .F:
9
This index is criticiCed for the !arge &eighting gi-en to the aesthetic comonent and has not
"et gained &idesread acceta)i!it". ;ut the index has )een ro-en to corre!ate &ith atient=s
oinions of aesthetic+ function+ seech and treatment need. @12A The strength of association+
ho&e-er+ &as !o&.
In 2((F Ni>in Ren et a!.+ in-estigated the su)>ecti-e ercetion and o)>ecti-e treatment need
and com!exit" of a num)er of atients see%ing orthodontic re.treatment. These atients had
good ercetion of denta! aesthetics and strong moti-ation. Their chief com!aints &ere
remaining denta! irregu!arit"+ rominent uer anterior teeth+ and<or an undesira)!e facia!
rofi!e. The stud" sho&ed that the" had an o)>ecti-e treatment need+ indicated )" the ICON
scores. @13A
Regarding atients treated &ith a com)ined orthodontic and orthognathic aroach+ a stud"
done )" ,.#. Tem!eton et a!. sho&s that )oth PAR and ICON are suita)!e occ!usa! indices
for assessing outcome and imro-ement. @15A
Assessin% treatment outcome* I(ON com#ared to &A'+
ICON is a unified index that+ in contrast to PAR+ assesses a!ong &ith treatment outcome e-en
treatment need and com!exit". The PAR index=s a)i!it" to assess com!exit" is !imited. @1:A
In addition+ there are different &eightings s"stems a-ai!a)!e according to the t"e of
ma!occ!usion+ assessment and the countr" in &hich it is underta%en. The ICON is de-e!oed
to reresent internationa! oinion for a!! facets of ma!occ!usions.
ICON is a re!ati-e!" sim!e index to use re'uiring no hierarch" &ith re!ati-e!" fe& traits to
measure. A!ication of this index ta%es aroximate!" 2 minutes for each case and therefore+
it is re!ati-e!" 'uic%. It re'uires no measurement too!s other than an ordinar" mi!!imeter ru!e
and an Aesthetic comonent sca!e. @14A
The aim of this stud" is to assess ICON on atients treated at ,aro!ins%a Institute+ $eartment
of $enta! #edicine+ $i-ision of Orthodontics.
1
0
2. ,ateria"s and methods
Of the 2*6 atients &ho had their com!ex orthodontic treatment com!eted "ear 2((F at
,aro!ins%a Institute+ $eartment of $enta! #edicine+ $i-ision of Orthodontics. (0toc%ho!m)+
aroximate!" 1( 7 (3( atients) &ere chosen from a !ist of atients &ith com!ete treatment
&ith the on!" criteria of com!ete stud" mode!s )efore and after treatment. Of these atients+
1F &ere fema!e and 12 ma!e &ith a mean age 15 at the start of the treatment. @Ta)!e AA. The
atients &ere treated )" )oth ostgraduate students in orthodontics and trained orthodontists.
Patients &ith incom!ete stud" mode!s &ere exc!uded and re!aced &ith the fo!!o&ing atient
on the !ist. The atients had an age range )et&een * and 2( "ears at the start of treatment. The
age and gender of a!! atients &ere noted and the duration of the treatment &as recorded. The
ICON scores &ere ca!cu!ated for the re.treatment and ost.treatment mode!s. The resu!ts
&ere ca!i)rated )" m" suer-isor+ associate rofessor 2ena ;erg!und.
0te-en)erg.
Tab"e A. Pre.treatment
ICON scores
,a"e
$%
$ema"e
$&
Number treated
'(
,ean a%e at start
$)
,ean start I(ON
*(,*
An exam!e of ho& the atients stud" mode!s &ere assessed fo!!o&s as )e!o&3
The atients re.treatment stud" mode!s (fig. 3a.3c) &ere e-a!uated as * on the sca!e of AC
&hich &as mu!ti!ied &ith 6 according to the ca!cu!ation ta)!e. Next ste in the assessment
rocedure is the cro&ding<sacing grade+ in this case cro&ding &as graded as : (L 16 mm)
&hich &as mu!ti!ied &ith :. Cross)ite &as resent &hich ga-e us a num)er of 1 and &as
mu!ti!ied &ith :. Eina!!"+ the oen)ite<dee)ite &as e-a!uated a!ong &ith )ucca! segment in
anteroosterior asect to a score of 1 and 2 resecti-e!"+ )oth &ere mu!ti!ied &ith 5. The
ca!cu!ation of a!! these digits ga-e us a tota! re.ICON score of 1(: !eading to com!exit"
grade of -er" difficu!t (L66).
Figure 3a
Figure 3b Figure 3c
The ost.treatment stud" mode!s (fig. 5a D 5c) &ere assessed as 1 on the AC.sca!e. A!! other
comonents+ excet the anteroosterior )ucca! re!ation that &as scored 1 (G5)+ &ere gi-en the
score ( gi-ing a ost.treatment ICON.score 1(. In order to get the imro-ement grade+ the
fo!!o&ing e'uation &as used3
Pre.treatment score D 5 times ost.treatment score
In this case the ca!cu!ation &as therefore 1(:.(5G1() M 4: resu!ting in a great!" imro-ed
outcome (L .1).
Figure 4a
Figure 4b Figure 4c
3. 'esu"ts
The atients &ho &ere chosen for this stud" had a mean ICON score of 6(+6 at the start of the
treatment @Ta)!e AA. Out of these atients on!" t&o had com!exit" grade /as" &hi!e 13
atients had Ker" difficu!t @Ta)!e ;A. The treatment had a mean duration of 25+6 months
)eginning from the !anned extractions or )onding of the orthodontic )rac%ets. After the
com!ete treatment+ the ca!cu!ation of mean ICON score &as recorded to )e *+3 sho&ing a
reduction of 41+5 ICON oints @Ta)!e CA. The distri)ution of re and ost treatment ICON.
scores for a!! the cases are resented in ta)!e /. None of the atients sho&ed a !esser
imro-ement than su)stantia!. 23 atients8 667 sho&ed great imro-ement. Remaining 6
atients+ 237 sho&ed su)stantia! imro-ement @Ta)!e $A.
Tab"e -. Distribution of compleit! grade
Tab"e (. Post"treatment ICON scores
,a"e
$%
$ema"e
$&
Number treated
'(
,ean finish a%e
$+,'
,ean duration (months
%),*
,ean finish I(ON .core
,,'
Tab"e !.Distribution of impro#ement grade
Tab"e /. Distribution of pre and post treatment ICON scores for the 3$ patients
5. !iscussion
0e-era! indices ha-e )een used for the assessment of orthodontic treatment need and
treatment outcome. In order to ha-e a standardiCed s"stem+ it &ou!d )e idea! to ha-e an index
that co-ers )oth uroses. 0uch an index has )een roosed in form of ICON+ )ut this index
is not "et common!" used. ;eside the fact that other indices ha-e )een used during man"
"ears+ the ICON index has not )een assessed in enough 'ua!it" contro! studies. #ore 'ua!it"
contro! studies are needed in order to ha-e this unified index as more genera!!" acceted
index.
In order to assess the outcome of orthodontic treatment &ith ICON index+ I rinted out a !ist
of a!! atients &ho had undergone a com!ete orthodontic treatment and finished the treatment
at ,aro!ins%a Institutet during the "ear of 2((F. 3( atients &ere chosen mar%ed random!" on
the !ist. ?a-ing com!ete re.treatment and ost.treatment stud" mode!s &as the on!" criteria.
?ence+ F stud" mode!s &ere exc!uded &here the stud" mode!s &ere either incom!ete or too
damaged to )e used for this urose. These mode!s &ere re!aced )" the next resecti-e
names on the !ist.
I thin% ICON is a !ia)!e index and eas" to use. The on!" e'uiment needed for this urose is
a measuring ru!er and stud" mode!s re. and ost.treatment. The instructions for scoring and
the cut off -a!ues are distinct and eas" to fo!!o&. The mode!s for the first case too% around 1(
minutes each to assess )ut &hen I had got more fami!iar &ith the ICON s"stem+ each atient
too% around 2 minutes.
ICON is the first index )ased on the a-erage oinion of a !arge ane! of internationa!
orthodontic oinions. It is de-e!oed to ena)!e assessments of treatment need and outcome
using a set of fi-e occ!usa! traits and for this reason it offers c!ear ad-ances on the current!"
used methods8 IOTN and PAR.
ICON is a re!ati-e!" ne& index and is not used &ide!" "et. It is criticiCed for )eing a method
hea-i!" &eighted )" aesthetics. According to a stud" erformed )" Ngom PI et a!. the
treatment need &as assessed for 44: 0enega!ese schoo!chi!dren aged 12.13. @16A IOTN and
ICON indices &ere used for this urose. 52+4 7 of cases assessed &ith the denta! hea!th
comonent of IOTN had treatment need &hi!e 55+1 7 of cases assessed &ith ICON had
treatment need. It cou!d )e conc!uded that in site of the hea-i!" &eighted aesthetic factor+
treatment need according to ICON does not differ much from the resu!ts &ith IOTN.
On"easo CO and ;ego!e /A @1FA ha-e in their stud" examined the re!ationshi among 5
indices that are used to score orthodontic treatment need and outcome+ and to determine
&hether ICON index cou!d re!ace the other 3 indices8 denta! aesthetic index+ PAR and the
American ;oard of Orthodontics o)>ecti-e grading s"stem (A;O.O90). 1(( re.treatment
and ost.treatment stud" mode!s &ere random!" se!ected from an accredited graduate
orthodontic c!inic at 1ni-ersit" of I!!inois at Chicago+ Chicago+ I!!. This stud" sho&ed that the
ICON can )e used in !ace of the PAR and the A;O.O90 for assessing treatment outcome
and in !ace of the $AI for assessing treatment need.
A stud" done )" 0. Richmond et a!. in #a!mO had the aim of assessing the orthodontic
treatment ser-ice ro-ided )" 4 orthodontists in a grou ractice.
@1*A The stud" mode!s of 1(( atients treated orthodontica!!" in the office &ere assessed &ith
ICON. 3 cases &ere >udged as not re'uiring orthodontic treatment and 34 (347) cases &ere
c!assified as -er" difficu!t to treat. 617 of the cases exhi)ited acceta)!e finishes &hi!e 47
sho&ed a continued need of treatment. The treatment on a-erage too% 22 months.
In m" stud" a!! the atients chosen had a treatment need (most of them a great treatment need)
according to ICON scoring s"stem. A!! these atients had got an orthodontic chec% to get free
treatment. In contrar" to Richmonds stud"+ none of m" cases sho&ed !ess than su)stantia!
imro-ement. 667 sho&ed great imro-ement &hi!e 237 had imro-ed su)stantia!!". The
treatment too% aroximate!" 25 months on a-erage.
4. (onc"usions
In this stud"+ the com!ete orthodontic treatments of 3( atients at the ,aro!ins%a Institute
&ere assessed &ith ICON+ Index of com!exit"+ outcome and need. 66 7 of these cases &ere
great!" imro-ed+ 23 7 sho&ed su)stantia! imro-ement &hi!e none of the atients &as in
need of further treatment+ in other &ords+ satisf"ing treatment resu!ts.
It &as first time for me to come in contact &ith ICON and &or% &ith it. The index is sim!e to
!earn and use. After a 'uic% ca!i)ration a!! "ou need is the re. and ost.treatment stud"
mode!s+ and a measuring ru!er.
6. Ac0no1"ed%ments
I &ou!d !i%e to than% m" suer-isor associate rofessor 2ena ;erg!und.0te-en)erg for
exce!!ent guidance+ "our exertise and suort made this ro>ect ossi)!e. I &ou!d a!so !i%e to
than% the nurses Anita Pohansson and ?e!enQ ;oh!in at the deartment of Orthodontics for
their he! &ith stud" mode!s and >ourna!s. 2ast )ut not !east I &ant to than% Professor Pan
?uggare for introducing me to this ro>ect.
7. 'eferences
1. Na)i! #oc%)i!+ Pan ?uggare 1niformit" in se!ection for su)sidiCed orthodontic care D
focus on )order!ine treatment need. %wedish dental &ournal+ 33+ 1*.2:
2. ?ans ;Rc%strOm+ ;engt #oh!in. Sua!it" assessment in orthodontics using the IOTN
and PAR indices+ 'Tandl()artidningen' *(34+ 1**F
3. $anie!s+ C. and Richmond+ 0. (2(((). The de-e!oment of the Index of Com!exit"+
Outcome and Need (ICON). &ournal of Orthodontics+ 27+ 15*.42
5. Ather!" A+ Cu!!er 0+ ;ec%er / 2((( The ro!e of cost.effecti-eness ana!"sis in hea!th
e-a!uation. *uarterl! &ournal of Nuclear +edicine 553112.12(s
:. P. $ean+ R. P!a"!e+ P. $urning and 0. Richmond. An ex!orator" stud" of the cost.
effecti-eness of orthodontic care in se-en /uroean countries. ,uropean &ournal of
Orthodontics 31(2((*) *(.*5
4. Richmond+ 0.+ 0ha&+ H. C.+ OT;rien+ ,. $.+ ;uchanan+ I. ;.+ Pones+ R.+ 0tehens+ C.
$.+ et a!. (1**2). The de-e!oment of the PAR index (Peer Assessment Rating)3
re!ia)i!it" and -a!idit". ,uropean &ournal of Orthodontics+ 14+ 12:.3*
6. Richmond+ 0.+ 0ha&+H.C.+ OU;rien+ ,. $.+ ;uchanan+ I. ;.+ Pones+ R.+ 0tehens+ C+
$.+ Ro)ert+ C. T. and Andre&s+ #. (1**2) The de-e!oment of the PAR Index (Peer
Assessment Rating)3 re!ia)i!it" and -a!idit"+ ,uropean &ournal of Orthodonitcs+ 15+
12:.15(
F. Richmond+ 0.+ 0ha&+ H. C.+ OU;rien+ ,. $.+ ;uchanan+ I. ;.+ 0tehens+ C. $.+
Andre&s+ #. and Ro)erts+ C.T.(1**:) The re!ationshi )et&een IOTN and the
consensus oinion of a ane! of 65 dentists+ -ritish Dental &ournal+ 16F+ 36(.365
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