in finnish health centres , orthodontic treatment is an important part of children 's and adolescents ' 
 dental services , all of which are free of charge up to the age of 18 years . in the 
 early 1990s , every fourth dental visit of children and adolescents to the 
 health centres was connected with orthodontic treatment . however , during 
 the economic depression later in the1990s , most health centres had to restrict 
 their expenditure . at the same time , the focus in public dental health care was 
 gradually changing , and today , dental care for adults of all ages is also included 
 in the services .   despite this 
 development , it is generally accepted that children 's dental services should 
 not be endangered . each municipal health centre can decide on the extent of 
 services they want to deliver . consequently , the access to orthodontic 
 treatment varies considerably [ 2 , 3 ] . 
				 in countries with publicly funded 
 orthodontic services , dentists play a dominant role in the initiation of 
 orthodontic treatment [ 4 , 5 ] . the access to orthodontic treatment is influenced 
 by two main factors ; the rates of referrals to orthodontists for assessment and 
 the sufficiency of services . according to shaw et al . , the referral rate is 
 influenced by the thoroughness of examination , the consistency of the 
 assessment of treatment need , and the perceived efficacy of treatment . different guidelines have been developed for the assessment of orthodontic 
 treatment need , but they do not seem to have much impact on the practices of 
 the general dental practitioners . in finland , the most frequently applied method 
 in the assessment of treatment need is a 10-grade scale modified from grainger 's 
 tpi - index   by heikinheimo   that is used in the majority of health centres . 
 on the scale , grade ten represents the most severe malocclusions or 
 craniofacial malformations , and grade one no malocclusion . the most frequently 
 applied cut - off level entitling to treatment is 7 . however , in different health 
 centres the cut - off level varies between grades 2 and 8 according to the 
 resources of the health centre . the availability of services is 
 greatly influenced by the distribution of orthodontic manpower . in most western 
 countries , the majority of specialists live in the largest cities or in the 
 most densely populated areas . in sparsely populated areas , this may lead either 
 to restrictions in access to orthodontic treatment or to orthodontic treatment 
 given by general dentists . in finland , the availability of specialist 
 expertise varies in different areas of the country . in most health centres , the 
 role of specialist orthodontists is central in diagnostics and treatment 
 planning , but general dentists commonly provide treatment at least in all centres other than the 
 largest health centres . when public orthodontic care of 
 children and adolescents is evaluated , it is important to study both the 
 changes in orthodontic services as such and the perspective of the entire dental 
 health care . the aim of this study was to examine orthodontic care in finnish 
 municipal health centres in 2001 , and to assess the prevailing state and 
 development during the past ten years as viewed by the local chief dental 
 officers and the orthodontic specialists working in the health centres . in april 2002 , two different semistructured 
 questionnaires were sent out to survey the views on orthodontic care in 
 finland . a questionnaire was sent to all local chief dental officers in 276 
 finnish municipal health centres . the questionnaire was based on an earlier 
 questionnaire , which mapped out the orthodontic care in finnish health centres 
 in 1992 , and it inquired about the number of personnel involved in 
 orthodontic care , their work division , the number of orthodontic patients and 
 visits , the use of removable and fixed orthodontic 
 appliances , changes in orthodontic care in the previous ten years , and the 
 chief dental officers ' own view on what further orthodontic research is needed . a follow - up letter was sent to the chief dental 
 officers who did not respond by the appointed time . another different questionnaire was sent to all 146 specialist 
 orthodontists under 65 years of age living in finland in 2001 , regardless of their 
 type of employment . the names and addresses of the orthodontists were obtained 
 from the files of the finnish dental society . the answers received concerning 
 the optimal timing of orthodontic treatment , the main indications for starting 
 treatment in children at each developmental stage of occlusion , and the respondents ' 
 choice of appliances have been analyzed in a previous study . the present study includes only the answers of those respondents who 
 worked in the health centres as salaried specialists or consultant 
 orthodontists , or who provided commissioned orthodontic services for health 
 centres , because they possessed real facts about activities in health centres 
 instead of just beliefs . the orthodontists were asked to evaluate , in open 
 questions , orthodontic services and optimal work division in municipal health 
 centres , to report recent changes in their treatment practices , to give 
 suggestions for improvement of orthodontic care , and to suggest orthodontic 
 issues needing further research . responses were received from 177 
 chief dental officers , and after a follow - up letter , from a further 30 respondents . the nonresponding chief dental officers worked 
 mainly in small health centres covering areas with fewer than 10  000 inhabitants . six nonresponding chief dental officers worked in health centres covering 
 areas with 10  00020  000 , another 
 six with 20  00050  000 , and one with 
 over 50  000 inhabitants . in all thirteen of them had no connection with health 
 centres and were excluded from the study ; 70 respondents working in or cooperating 
 with health centres were included in the study . twenty - two of the 63 nonrespondents 
 worked in the health centres as salaried orthodontists , and ten cooperated as 
 consultant orthodontists with the health centres . the response rate was 68% , when 
 only the respondents and nonrespondents working in or cooperating with the 
 health centres were included . the volume of orthodontic services was 
 measured by the percentage of 018-year - olds 
 wearing orthodontic appliances in 2001 , the mean percentage being 11.4 ( sd 6.4 , 
 range 243% ) . the mean 
 percentage of children wearing an appliance was the highest in small health 
 centres with fewer than 10  000 inhabitants . the mean percentage was slightly smaller 
 in larger centres , but the differences were not statistically significant . the 
 percentage of orthodontic visits of all dental visits of the 018-year - olds was , 
 on average , 30.7 ( sd 10.6 , range 266% among health 
 centres ) , and the size of the health centre was not associated with the ratio 
 of orthodontic visits ( table 1 ) . a quadhelix was the most frequently 
 used appliance in primary dentition , followed by an eruption guidance 
 appliance . a headgear was the most frequently used appliance both in the age 
 group of 7 to 9 years , and in the age group of 10 to 13 years ( table 2 ) . the most frequent way to obtain 
 orthodontic expertise , used by 74% of health centres , was by making a contract 
 with a consultant orthodontist . the purchasing of commissioned services was most frequent in the small 
 health centres with fewer than 20  000 inhabitants . five percent of health 
 centres did not have any specialist expertise at their disposal . the ways of 
 obtaining orthodontic expertise in the health centres of different sizes are 
 given in table 3 . specialist orthodontists ' working time represented 22% of the 
 total working time spent on orthodontic treatments in all the responding health 
 centres . in almost all the health centres ( 94% ) , 
 general dentists treated some of the orthodontic patients . the working 
 time they spent on orthodontic treatments represented 64% of the total working 
 time spent on orthodontic care in the health centres . delegation of orthodontic tasks to dental 
 auxiliaries was used in 61% of health centres , and their working time 
 represented 14% of the total working time spent on orthodontic care in the 
 health centres . seventy - four percent of chief dental officers reported major 
 changes in the organization of orthodontic services during the previous five 
 years . in thirty - four health centres , major changes had taken place in the 
 volume of orthodontic services ( table 4 ) . the number of specialist orthodontists had 
 increased in twenty - seven and decreased in seven health centres . the   specialist orthodontists proposed that specialists 
 should not give simple orthodontic treatment but concentrate on treatment 
 planning , consultation , and difficult treatment . forty - five respondents ( 64% ) wanted 
 to change the work division between specialists and general dentists ; thirty - three 
 ( 47% ) wanted to increase the share of general dentists mainly by delegating 
 simpler treatments to them : treatment with appliances such as quadhelix , headgear , 
 activator , face mask , and removable appliances . seventeen respondents ( 24% ) wanted 
 to decrease the involvement of general dentists in difficult treatments and the 
 number of treatments started independently , without consultation . only one specialist orthodontist wanted to decrease 
 delegation to auxiliaries , while 65 of them wanted to increase delegation by 
 devolving routine tasks more often . the most common tasks to be delegated were 
 the taking of impressions ( 51% of respondents answering this question ) , 
 rebonding ( 50% ) , setting of bands ( 50% ) , health education and motivation ( 42% ) , 
 bonding of brackets ( 15% ) , and changing of ligatures and arch wires ( 8% ) . eighty - one percent of specialist orthodontists had made some 
 changes in their treatment practices during the preceding ten years . the most 
 frequent changes concerned the application of new treatment techniques ( 71% ) , 
 and of these , the adoption of an eruption guidance appliance was most common ( 36% ) . secondly , respondents reported changes in the 
 timing of treatment ( 54% ) , with the majority ( 75% ) moving to an earlier 
 starting age . thirdly , fourteen respondents were delegating orthodontic tasks 
 to general dentists or auxiliaries more often . when the specialist orthodontists 
 were asked to name those features of finnish orthodontic care they considered 
 to be of good quality , 55% listed the population - based system in the organization 
 of orthodontic services , 25% the good professional skills of specialists , and 20% 
 professional skills in the execution of early treatment . when assessing public orthodontic 
 care as a whole , the orthodontists complained about the wide variation in the 
 access to orthodontic treatment and unsatisfactory routines in the treatment 
 processes the most frequently mentioned improvement suggestion was an increase 
 in specialist manpower ( table 5 ) . both respondent groups stressed the 
 need for research on treatment outcome and stability of treatment results . the 
 efficacy of treatment methods was similarly mentioned by both groups , while the 
 need for studies on cost - effectiveness was especially emphasized by the 
 orthodontists ( table 6 ) . there was a wide variation in the 
 extent of orthodontic services among finnish health centres . the variation in 
 the access and delivery of treatment also seemed to be the main concern among 
 the orthodontists working in or cooperating with health centres . the economic 
 depression in the 1990s had not been directly reflected in the extent of orthodontic 
 services , and more health centres had increased than decreased their services 
 during the last decade . the earlier survey on public 
 orthodontic care of children and adolescents in finnish municipal health 
 centres made it possible to evaluate the changes in services during the 
 ten - year period . the overall extent of services had generally increased , but 
 the 20-fold differences among health centres still prevailed . a new appliance , the 
 eruption guidance appliance , was introduced during the period . the eruption 
 guidance appliance seemed to have replaced the use of removable plates and 
 functional appliances in the early treatment group . delegation of orthodontic 
 tasks to auxiliaries had increased , and delegation was widely accepted by the 
 orthodontists . the majority 
 of the nonresponding health centres were smaller ones , which obviously had more 
 difficulties in collecting the retrospective data . because this evaluation 
 concentrated on public services provided in municipal health centres , it was justified 
 to include only the views of the orthodontists working in or cooperating with 
 the health centres . the methods of measuring the volume 
 of orthodontic treatment vary in different countries , and this hampers reliable 
 comparisons [ 3 , 12 , 13 ] . according to chestnutt et al . , the extent of 
 orthodontic treatment also increased in britain between 1993 and 2003 . correspondingly , 
 we found that the mean percentage of children and adolescents receiving 
 orthodontic treatment had increased from 7.6% in 1992 to 11.4% in 2001 . the average share of orthodontic 
 visits of all dental visits of children and adolescents had increased slightly 
 from 26% in 1992   to 30% in this study . an explanation for the increase in 
 this ratio is the simultaneous decrease in numbers of general dental visits . furthermore , in 1998 , the national research and development centre for welfare 
 and health published a report recommending longer oral examination intervals in 
 children and adolescents . however , the large variation among health 
 centres in the share of orthodontic visits ( 266% ) can not be plainly 
 explained by this change . most of the changes in providing 
 orthodontic services were related to the availability of specialist manpower ; 
 an increase in the number of orthodontists was reported more often than a lack 
 of specialists . the possibilities to organize specialist services seem to 
 differ between small and large health centres . when compared with the earlier study , 
 the availability of health centres ' own orthodontic expertise had slightly increased , 
 as the percentage of health centres employing their own salaried specialist had 
 increased from 18% to 21% . all municipalities , regardless of their size , 
 have an equal responsibility to organize treatment even in the most severe 
 cases . this might be one reason why the percentage of health centres purchasing 
 commissioned services had increased from 8% in 1992 to 34% in 2001 . according to the respondents in the present study , the weakened 
 economic situation was the most frequent reason for reducing children 's 
 orthodontic services . the effects of economic restraints on the public 
 orthodontic services have been evaluated in denmark and in sweden [ 16 , 17 ] . according 
 to linder - aronson et al . , the restrictions of orthodontic services 
 can not be defended by a decreasing need of treatment . actually , the restriction of access to 
 orthodontic treatment seems to lead to an increased consumption of resources . 
 in sweden , the economic restraints seemed to decrease the number of treatments 
 provided by general dentists and the use of appliances demanding good 
 compliance . it has been suggested that the costs 
 of orthodontic services could be lowered by changes in the division of work and 
 by delegation of tasks to dental auxiliaries . the delegation of 
 orthodontic tasks is an acceptable practice in all nordic countries , but is 
 applied most widely in denmark and sweden . in sweden , the work division is also 
 facilitated by the systematic training of orthodontic assistants . in 
 finland , the share of health centres applying delegation of orthodontic tasks 
 to auxiliaries had increased from 28% to 61% from 1991 to 2001 . they 
 were also interested in devolving simpler orthodontic treatments to general 
 dentists with the premise that the planning of treatment was carried out by 
 specialists . the orthodontists were concerned about the great variation 
 in the delivery of orthodontic care and almost half of them suggested that national 
 guidelines should be established to reduce this variation . the development of 
 guidelines has also been suggested earlier as a good tool for reducing 
 variation in the provision of health services [ 21 , 22 ] . guidelines on the screening 
 of malocclusions and the assessment of treatment need could diminish the 
 variation in access to and volume of treatment . furthermore , the inefficient routines 
 used in the planning and documentation of treatments , which were also mentioned , 
 could be improved by national guidelines . national guidelines and delegation of orthodontic tasks were 
 suggested as principal tools for reducing the wide variation among the health 
 centres . thus , 
 the orthodontists ' suggestion to increase the number of specialist 
 orthodontists is justified . additional 
 resources for orthodontic services should be established without further delay 
 by organizing local and national training for auxiliary personnel working in 
 orthodontic teams . furthermore , development of national guidelines for the orthodontic 
 treatment process might increase both the uniformity and effectiveness of 
 treatment .
the study maps out orthodontic care in finnish municipal health centres in 2001 , describes changes during the previous ten years reported by chief dental officers , and assesses the views of orthodontists on current public orthodontic services . 
 the data were collected by questionnaires sent to all health centres and all orthodontists in finland . of all 018-year - olds , 
 11% were receiving orthodontic treatment with an appliance ( range 243% among the health centres ) . 
 the most frequently used appliances were headgear , quadhelix , and fixed appliances . 
 limited economic resources and the lack of orthodontic expertise were mentioned by the chief dental officers as factors decreasing the volume of services . 
 the orthodontists mentioned the large regional variation and the lack of national guidelines as the most important aspects that should be improved on a national basis . to bring about improvement , 
 they suggested increasing the number of specialist orthodontists and the delegation of orthodontic tasks to auxiliaries .