Standardised proformas for the management of hypodontia patients: A new standard for clinical documentation

Abstract

Background:

Hypodontia is a common dental anomaly with complex treatment needs that often require a multidisciplinary approach. Despite its impact on aesthetics, function and psychosocial well-being, there remains a lack of standardised protocols for managing multidisciplinary services for patients with hypodontia.

Objective:

This paper describes the development and implementation of standardised proforma templates as part of a local standard operating procedure (SOP) for the management of patients with hypodontia at the Royal London Dental Hospital (RLH), with the broader goal of informing wider data collection efforts.

Methods:

Four proforma templates were created to standardise documentation at key stages of the patient pathway: initial referral (appendix 1), new patient assessment (appendix 2), initial treatment plan (appendix 3) and mid-treatment review (appendix 4). These have been implemented within the RLH service for patients with hypodontia.

Results:

The introduction of the templates has been seen to enhance compliance with local SOPs, improve consistency in clinical documentation, and facilitate more robust data collection and analysis.

Conclusion:

The implementation of standardised proformas represents a significant step toward unified data collection and improved multidisciplinary care in hypodontia management. Their broader adoption could support quality improvement initiatives, ensure alignment with NHS governance standards and contribute to the development of a national hypodontia database.

Plain language summary

A new set of standard forms for collecting information in patients born with missing teeth

Why was the study done? Some people are born missing one or more adult teeth. This condition is called hypodontia. It can affect how people look, eat and feel about their smile. Treatment often needs several dental specialists to work together. Until now, there has been no clear or consistent way for clinics to record and plan this care. This study aimed to create simple and standard forms, called proformas, to help dentists manage hypodontia patients more effectively.

What did the researchers do? The team at the Royal London Dental Hospital worked together to design four new forms. Each form helps at a different stage of a patient’s journey: (1) when the patient is first referred to the clinic; (2) when the patient has their first assessment; (3) when the treatment plan is made; and (4) when the patient’s care is reviewed. The forms were tested in the hospital’s hypodontia service to see how well they worked in real practice.

What did the researchers find? The new forms made care more consistent and easier to follow. They helped the team record information clearly and check that treatment matched local standards. They also made it easier to collect information for research and service audits. Overall, the forms improved teamwork and helped staff manage complex cases more smoothly.

What do the findings mean? These standard forms can help improve the quality and safety of hypodontia care. They make it easier for different dental teams to work together and share information. In the future, using the same forms across the UK could help build a national database. This would support better research, planning and outcomes for patients with missing teeth.

Background

Hypodontia is regarded as the most common dental developmental disorder and it is characterised by the absence of at least one permanent tooth, not including third molars, with an overall prevalence of up to 6.4% (Khalaf et al., 2014). It can be associated with syndromes and conditions such as Down’s syndrome (Cobourne, 2007). Hypodontia has been found to have detrimental effects on the quality of life of patients, including negative effects on aesthetics, function and psychosocial factors (Johal et al., 2022; Locker et al., 2010; Wong et al., 2006). The management of hypodontia can be complex and often requires a multidisciplinary approach. With no single dental specialty possessing the varied expertise required to treat this patient cohort optimally, then multiple dental specialties are ideally involved. This includes the orthodontic, restorative, paediatric, and oral surgery and maxillofacial teams, and it is reported that a clear and agreed definitive treatment plan will allow the multiple dental disciplines to streamline their care with the objective of improving patient outcomes (O’Sullivan and O’Connell, 2017).

There is an increased focus on monitoring clinical outcomes of patients undertaking treatment through the use of proformas, standard operating procedures (SOPs) and database systems. These are crucial in helping to monitor patients through their care pathway and can also help facilitate audit and research. This is an essential part of clinical governance, allowing for quality improvement at a local and national level within the National Health Service (NHS) but could also be applicable to clinicians globally (Scally and Donaldson, 1998).

To date, there are no known reports on the use of standardised proformas or SOPs for the management of hypodontia patients. A set of SOPs for the management of patients with hypodontia would allow for clear roles, responsibilities and processes to be set within the hypodontia team, as well as to ensure compliance with national recommendations, and to maintain accuracy and timeliness of data (Kee, 2011).

The implementation of proformas, as part of a SOP within the discipline of hypodontia management, can also assist in the subsequent development of a database system. The use of databases within orthodontics has been seldom reported on, and there appears to be no known reports of their development in hypodontia. Clinicians of specialist-led clinics, such as those involving the care of patients with hypodontia, are encouraged to share their existing caseloads to facilitate the identification of such patients. A database would allow for this, as well as keeping a record of the number of patients being managed. This would help to demonstrate both the needs, and costs, of running the specialist-led services, as higher complexity treatments tend to have higher costs in comparison to typical orthodontic treatment (Deacon et al., 2007).

The use of well-developed database systems has been advocated as a way of allowing patients to be identified and tracked, such as the use of a centralised care model for children born with a unilateral cleft lip and palate (Sandy et al., 1998). In the UK, the CRANE Database was set up by the Department of Health in 2000 and it collects information about all children born with cleft lip and/or cleft palate (CRANE - The Cleft Registry and Audit Network, 2024). In relation to orthodontics, comprehensive archive systems have been used, such as The University of North Carolina (UNC) Dentofacial Program database, which contains over 3000 patients with initial records, and over 1400 patients with at least 1 year of follow-up (Bailey et al., 2004). A core outcome set for orthodontic research has been developed that encompasses both patient- and clinician-focused outcomes (Tsichlaki et al., 2020), and any potential future database would ideally collect data that correspond as best as possible to the core outcome set.

A database of patients undergoing treatment for hypodontia would be of great benefit. To create such a database, information would need to be gathered from the treating units by collecting the baseline information of the management of such patients. The team at the Royal London Dental Hospital (RLH), with the financial support of the British Orthodontic Society, is currently evaluating the service provision for patients with hypodontia throughout the UK, with the ultimate goal of establishing a national database for hypodontia. Collection of these data would ideally be accomplished via a standardised electronic data collection form. The creation of standardised proformas for hypodontia has been identified as a valuable and helpful step towards standardised data collection.

Proforma development

The hypodontia team at the RLH (AJ, FW, SS, PH, SS, KR) offers advice and a diagnostic service for any clinician referring a patient who meets the acceptance criteria. The service is for people under the age of 18 years presenting with an orthodontic malocclusion of significant need, i.e. Index of Treatment Need (IOTN) Dental Health Component 4 or 5. Local hospital trust policy allows treatment only for those patients aged over 18 years who require corrective jaw surgery or experience obstructive sleep apnoea. Patients eligible for NHS treatment who present with milder malocclusions, or involving the replacement of a single unit, may be referred to a ‘Level 3a’ provider, i.e. a local specialist orthodontist, for comprehensive management. In such a patient, any restorative management would then be provided by their General Dental Practitioner (NHS England, 2023).

Four proforma templates were co-created by the multidisciplinary treatment team through consensus meetings and further discussions, with the aim to standardise documentation as part of the SOP for the management of patients with hypodontia at the Royal London Dental Hospital. The information included within the proforma templates has been designed to facilitate assessment of the compliance of care for patients with hypodontia in accordance with the local SOP.

The proformas cover the following: initial referral to the hypodontia clinic (Appendix 1); new patient assessment on the hypodontia clinic (Appendix 2); initial treatment plan (Appendix 3); and mid-treatment review (Appendix 4). The format of these proformas has been informed by the digital notes system used within the hospital, where the ability for ad hoc alterations is rather limited. We anticipate that these proformas might be reformatted to better suit other notes systems.

Discussion

These proforma templates have been designed to overcome the challenges frequently present at multidisciplinary clinics in hypodontia care, with the aim of providing a clearer pathway for patient care. Templates can help to improve consistency, enhance efficiency and reduce errors. The templates were further developed during an audit within the department, and it was concluded that the templates had significantly enhanced compliance with the SOP and had facilitated improved data analysis (Ming and Johal, 2023).

Standardised proforma templates are not only useful for improving patient care, but they also have the potential to be used to provide accountability to dental commissioners about the quantity and complexity of the treatment that is being provided for patients with hypodontia within the secondary care setting.

In addition, with wider use of the same standardised templates across different departments and across different care settings, future audit and research beyond a single department or site can be more easily facilitated. Following on from this, the use of standardised templates will be beneficial as part of the workflow for any potential national database for hypodontia.

There is a risk that standardised templates can override individual patient agendas, unless they have been designed to promote patient-centred care (Morrissey et al., 2021). Some further risks identified with template use in dentistry that might warrant consideration include inappropriate template use, irrelevant entries and unnecessarily lengthy notes that can distract from key facts, otherwise known as ‘note bloat’ (D’Cruz and Rattan, 2018). However, these risks can be relatively easily overcome with appropriate guidance and prompts within the standardised templates.

Conclusion

Establishing and implementing standardised proforma templates for the management of patients affected by hypodontia is crucial, providing benefits for subsequent audit, research, monitoring and appraisal processes. It is our hope that the details obtained from the use of such proformas can assist in the establishment of a standardised dataset for patients with hypodontia, and ultimately to help facilitate the creation of a national hypodontia database.