The Medical Necessity of Orthodontic Care: A Qualitative Study.

introductionAs global momentum builds for universal health coverage (UHC), it is unclear whether orthodontic care should be included in UHC packages. The concept of medically necessary orthodontic care (MNOC) and its criteria thus have far-reaching implications for priority setting and resource allocation in public and private oral health care programs.

objectiveTo identify factors that contribute to the determination of MNOC based on perspectives from leaders of dental professional organizations, academics, clinicians, funders, patient advocates, and patients from 7 countries: Canada, United States, Germany, Greece, United Kingdom, Switzerland, and Australia.

methodsA qualitative description design was used with semi-structured virtual interviews conducted via Zoom from November 2021 to August 2022. Interviews were transcribed verbatim, coded, and analyzed for themes.

resultsSixteen interviews were conducted. Participants described their concept of MNOC through 4 interrelated categories: (1) dental factors including dental health, the goals of treatment, and methods of needs assessment; (2) medical factors including the meaning of medical necessity, systemic health considerations, and treatment of craniofacial anomalies; (3) psychosocial factors including societal standards of beauty, social functioning, and mental health; and (4) funding factors including resource allocation considerations and the goals of funding.

conclusionThe diversity of factors identified highlights the complex interplay between the dental profession, funders of care, society, and individual patients in understanding MNOC. Given this complexity, MNOC is arguably not amenable to a concise definition or list of criteria. Instead, a decision-making process that incorporates key actor perspectives can enhance transparency, fairness, and accountability in priority setting and resource allocation as related to MNOC and medically necessary oral health care more broadly. This approach would ensure coverage for those with demonstrated need in the context of health, well-being, and quality of life.Knowledge Transfer Statement:This study provides critical insights into the dental, medical, psychosocial, and funding factors that influence the meaning of medically necessary orthodontic care (MNOC) from the perspectives of key actors in 7 high-income countries. The findings reveal that MNOC cannot be defined by a simple set of criteria. Instead, determinations of MNOC should be made through a decision-making process that incorporates a wide array of viewpoints. This approach ensures transparent and fair resource allocation, improving access to essential orthodontic services, thereby enhancing patient health and well-being.