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

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). Additionally, an anonymous survey was distributed via Google Forms® (Alphabet Inc. California, USA) in November 2023 to referring clinicians and advisors of the ROAR pathway to assess their views on the changes in the ROAR pathway and descriptive analysis was conducted. All cases received virtual advice within 10 days of the request. The most common dental diagnoses were 70% (47/67) cFPM, 12% (8/67) hypodontia, 7% (5/4 = 67) ectopic tooth, 6% (4/67), anterior crossbite and 5% (3/67) other possible need for interceptive orthodontic advice. Following presentation and discussion of the first SE in a departmental meeting, it was felt that some ROAR cases could receive advice from the specialist paediatric team without the need for an orthodontic opinion. Additionally, clinicians wanted support to improve their orthodontic referrals and to understand the reasoning for the advice provided. It was therefore agreed that all ROAR requests would be screened by the specialist paediatric team prior to forwarding the referral to ROAR. This screening provided an opportunity for teaching and feedback as well as the provision of clinical advice if appropriate. All cases received advice within 32 days and only 43% (20/47) required orthodontic advice. The most common dental diagnoses were 97% (41/47) cFPM, 6% (3/47) ectopic/impacted tooth, 4% (2/47) severe crowding and 2% (1/47) class II malocclusion. The survey assessing clinician views on the pathway was sent to 35 clinicians, including all who had referred a case through ROAR and all who act as advisors (HP and three paediatric dental specialists). All (4/4) advisors and 42% (13/31) of referrers responded. Most, 71% (12/17), had experience of the ROAR pathway before paediatric screening was introduced. All responders with previous experience of the pathway, 100% (12/12), agreed that ‘paediatric dental review prior to orthodontic advice improved the quality of the ROAR pathway’, citing that the change helped referrers understand the reasoning for an orthodontic opinion, focussed their questions for the orthodontist, gained a more holistic approach, improved efficiency, excluded inappropriate referrals and minimised the burden to the external orthodontist. Content analysis of free text comments found that prior to paediatric dental screening, referrers were unsure what to include in their ROAR referrals, did not know where to direct their queries and some advisors had concerns of inappropriate advice requests. Analysis of comments about the ROAR pathway after the introduction of paediatric dental screening found recurring themes of increased understanding of when to ask for orthodontic advice and how to phrase questions. There were recurring themes of ROAR being useful, quick and simple to use. 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. Alexandra Lyne, Ayesha Patel and Whittington CDS paediatric dentists.