Root Cause

Singapore Health JUL/AUG 2011

National Dental Centre of Singapore cuts waiting time for patients with braces.

It should have few emergencies, but National Dental Centre (NDC) of Singapore’s Department of Orthodontics, where its specialists correct misaligned teeth or jaws, was seeing unusually high numbers of patients walking in without an appointment.

Puzzled by the number of unscheduled appointments, Dr Chan Feng Yi, Registrar, Department of Orthodontics, NDC, led a team to tackle the problem. “We wanted to improve the quality of care by finding out why patients came for unscheduled visits,” she said.

Most of the department’s patients are seen for misaligned or irregular teeth, and are fitted with braces to correct the fault. The team discovered that although patients came back for their scheduled visits every six to eight weeks to have their braces reviewed and adjusted, many also made impromptu visits because of problems such as rubber bands breaking, wires poking their gums as well as other small discomforts.

Braces are fitted to correct crooked or gap teeth as well as over- or underbites. Metal brackets are fitted to each tooth and are connected to a wire, held in place by elastic bands. The dentist will tighten the wire gradually to force the teeth into the right position.

Rubber bands are also used for some patients to apply additional pressure to move jaws in directions that the braces alone can’t. The rubber bands are hooked around specially created hooks, which form part of the braces.

As the braces force the teeth to straighten, the wire may work itself out of the back bracket, or get bent so it rubs or pokes into gums or cheeks at the back of the mouth, causing discomfort. The rubber bands can also snap.

“Most patients who walked in were not in pain, but unsure about what to do. By explaining how braces work and the problems they might have during their scheduled visits,” said Dr Chan.

The problem of the rubber band breaking was solved by discarding the orange-coloured bands, which were found to be weaker than bands in other colours.

As for wires poking into gums and cheeks, Dr Chan said: “As teeth shift, it’s normal for the wire to start poking the gums. We started to give all our patients wax, which can cover the sharp parts of any wires poking out, to ease the discomfort. Now, we routinely give them wax,” she said.

But walk-in visits are sometimes necessary, such as when retainers (worn to keep teeth straight after braces are discarded) are lost. “If this happens, we ask them to come in to see us, as patients cannot do without their retainers for long,” said Dr Chan.


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