Sir, I write in reference to the paper Oral health-related quality of life and the IOTN index (BDJ 2008; 204: E12).

As a member of the original Bedfordshire PDS pilot from which the data for the above paper were derived, I read the paper with great interest and would like to comment on a number of points. I noted with a degree of dismay that there were a number of patients offered treatment despite little or no dental health need and also when the patient did not report any dental health impact. This does not reflect in the data collected by the PDS which explicitly required patients who embarked upon orthodontic treatment, to have an IOTN DHC 3 AC 6 or above. Only in exceptional circumstances, when permission from the PCT had been granted, were patients below these criteria treated.

In the paper it is assumed patients placed on review were being accepted for treatment even if the IOTN was below the PDS criteria. I would argue that this may not be an appropriate measure. Patients with a low IOTN may warrant being placed on review ... such as the management of dubious first molars, monitoring adverse skeletal growth in the growing class III malocclusion or monitoring dental development in patients in the late mixed dentition where there is the potential for crowding ... but these cases may end up being treated. These review patients would have a low IOTN, may not have a perceived need for braces, but would be placed in the treatment offered/little borderline need category. This is important because some of your conclusions reflect upon the inadequacies of the current system offering treatment to patients with little/borderline dental health need and in which the patient has no perceived need for a brace.

Asking for the child's perceived need for orthodontic treatment at this stage, also, is of concern. In life one's perception of need can be influenced by a host of appropriate or inappropriate life experiences. In the current study the patients will have already been seen by a dentist and referred, presumably creating or reinforcing the notion that there were problems with their teeth and raising the expectation that they were in need of a brace. Indeed some at this point may have been misled into the view that they had a dental impact and needed a brace, even in the absence of a significant dental problem. In such a case the denial of orthodontic treatment may have been appropriate.

The initial assessment, involving the IOTN score, is only the first step in progressing to orthodontic treatment. Other factors such as caries, poor OH etc may mean it is inappropriate to offer treatment to a patient. Once patients have been identified as appropriate for NHS treatment within the PDS criteria, it would be standard practice for a more exact treatment plan to be formulated and discussed with the patient and parent. At this point the option of doing nothing is discussed and patients are free to express their desire or otherwise for treatment. One would hope that at this point those patients who had a need, and once informed about that need, did not want a brace, would not get one. Or conversely those who thought they did not need a brace might, once faced with information regarding their malocclusion, opt for treatment. It is at this point that I would like to know which patients I am failing and if an oral health related quality of life measure would be of use. I don't think the study has addressed this, nor do I think it has made a sound case that it is essential to incorporate a socio-dental measure into the evaluation of need of orthodontic treatment.