Development of a virtual orthodontic advice pathway in a community dental service

Abstract

Whittington Health Dental Service (WHDS) provides specialist-led community-based paediatric dental services across 13 London boroughs. Virtual advice and guidance pathways were introduced for all specialties, to ensure patients can access specialist advice when necessary, across all of WHDS's 23 clinics.

Paediatric patients with compromised first permanent molars (cFPMs) often require orthodontic advice before commencing treatment.¹ This would have involved referral to a local orthodontic practice, taking 9–12 months to receive advice, and sometimes contributed to delayed care and patients being unable to receive treatment within the ideal treatment window.

In July 2021, WHDS collaborated with Dr Hemant Patel (HP), lead orthodontist of Angle House Orthodontics (AHO), to address this problem by introduction of the Rapid Orthodontic Advice Request (ROAR) pathway. AHO, is a group of 13 specialist orthodontic practices based across the same geographical location as WHDS and is one of the main orthodontic providers for these patients. The ROAR pathway involves the referring dentist sending a clinical summary with orthodontic photographs and radiographs to HP via email. HP would review the information and provide the advice needed to commence their dental treatment in the CDS, without the child having to wait for a face-to-face orthodontic appointment. The ROAR pathway is not commissioned, and it is therefore crucial to evaluate the pathway for effectiveness to minimise the number of referrals, such that HP's time, offered via goodwill, is used efficiently.

WHDS also provide a separate virtual advice pathway for specialist paediatric dentistry, the Paediatric Dental Advice Clinic (PDAC). It was noted that some patients were being referred through both pathways and involving the paediatric dental team in the ROAR pathway could improve efficiency.

A log of all ROAR requests is stored on an encrypted Microsoft Excel® (Microsoft Corporation, Redmond, USA) spreadsheet. The pathway was assessed through a SE in July 2022. Actions were taken to improve the virtual advice pathway to incorporate screening from the specialist paediatric dental team and a second SE was conducted in November 2023 to reassess the pathway (Table 1).

As services nationwide consider methods of incorporating virtual advice and guidance into their clinical pathways, these evaluations show the benefits of having a combined paediatric and orthodontic advice pathway. Paediatric screening of the orthodontic advice requests also provided an opportunity for teaching and upskilling the wider dental team.

Referrers highly valued feedback and advice from the paediatric team to improve their orthodontic referrals. Paediatric screening increased the time taken to receive advice from a maximum of 10–32 days. The longer response times coincided with periods of staff leave, and although the overall time for advice increased, it was still assessed to be very quick by referrers.

Service evaluations are incomplete without inclusion of parent/carer and patient views. Many WHDS parents/carers experience language and digital technology barriers or have low health literacy. Inclusion of parent/carer and patient views in a manner that overcomes these barriers has been incorporated into the action plan.