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An Overview of the Peer Assessment Rating (PAR) Index for Primary Dental
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 AN OVERVIEW OF THE PEER ASSESSMENT RATING (PAR)
INDEX FOR PRIMARY DENTAL CARE PRACTITIONERS

JAMES IJ GREEN
Prim Dent J. 2016;5(4):28-37

D
eveloping an accurate treatment
ABSTRACT outcome measure can be a
complex process because results
The Peer Assessment Rating (PAR) index is a valid and reliable measure of are not always easy to document. In
orthodontic treatment outcome and is the most widely accepted such index. orthodontics this should not be the
case as treatment records in the form
Assessing outcomes with the PAR index requires the examination of pre-treatment of study models, photographs and
and post-treatment orthodontic study models. Beginning with the pre-treatment radiographs should be readily available
models, a score is given to each feature that deviates from an ideal occlusion and measures that assess elements of
(all anatomical contact points adjacent, good interdigitation between posterior treatment, in terms of morphological
teeth and non-excessive overjet/overbite), the scores are then added together to change, can be applied to these records.
give a total that represents the severity of the malocclusion. The process is then An occlusal index is one such measure
repeated with the post-treatment models. The difference between the pre-treatment that has been defined as a systematic
and the post-treatment scores reflects the improvement that has taken place measuring device used in epidemiology
during treatment. A score of zero represents an ideal occlusion and in general and public health to quantify the
the higher the score, the more extensive the malocclusion. relationship of teeth and dental arches.1

It is currently a condition of the NHS orthodontic contract for providers to The Summers occlusal index,2 an index
monitor a proportion of their cases using the PAR index. This paper aims to of orthodontic treatment need, has been
provide primary dental care practitioners with an overview of the PAR index used to assess orthodontic treatment
and should provide a useful guide for those wishing to seek calibration in the outcomes3-5 and numerous indices using
use of the index. pre-treatment and post-treatment records
have been developed specifically for
this purpose.6-11

The World Health Organization

(WHO) published nine requirements
for dental indices12 and those for
an occlusal index are akin to these.
Summers added that it “should be
valid through time” as a tenth point
(see Table 1).13,14

Unlike the previous indices, the PAR

KEY WORDS
Clinical Effectiveness, Malocclusion,
Outcome Assessment, Outcome
Measures, Outcome Studies,
Orthodontics, Quality of Health
Care, Tooth Movement, Treatment
Effectiveness, Treatment Outcome
AUTHOR
James IJ Green
Maxillofacial and Dental Laboratory Manager,
Maxillofacial and Dental Department, Great
Ormond Street Hospital for Children, London
index has been shown to be both a
valid and reliable outcome measure.15
Development
of the PAR index
In 1987, the PAR index was developed
over the course of six meetings with a
group of ten experienced orthodontists
(the British Orthodontic Standards
Working Party).16 Records in the form
of more than 200 sets of study models
representing developmental as well as
pre-treatment and post-treatment stages
were examined and discussed until
agreement was reached regarding the

28 P R I M A R Y D E N TA L J O U R N A L
 TABLE 1 community dental officers and two
public health orthodontic administrators)
THE REQUIREMENTS OF AN OCCLUSAL INDEX12-14 to assess the extent to which the index
reflected current British orthodontic
1 Status of the group is expressed by a single number which corresponds to a opinion.15 Rating scale measurements
relative position on a finite scale with definite upper and lower limits; running were recorded to reflect each examiner’s
by progressive graduations from zero (i.e. absence of disease) to the ultimate opinion on the degree of change
point (i.e. disease in its terminal stage) between 234 pre-treatment and post-
treatment study models, and 16 sets of
2 Should be equally sensitive throughout the scale models were duplicated to permit double
determination. The models were PAR
3 Should correspond closely with the clinical importance of the
scored by each examiner, which resulted
disease stage it represents
in a high level of agreement between
4 Should be amendable to statistical analysis PAR and the panel’s opinion.15,18 As
with some previous indices,2,19,20 validity
5 Reproducible was improved by applying weightings
(multipliers) to the overjet (x6), overbite
6 Requisite equipment and instruments should be practicable in (x2) and centreline (x4) to reflect their
actual field situation significance. The weighted component
7 Examination procedure should require a minimum of judgement scores were then added together to give
an overall total weighted PAR score.
8 Should be facile enough to permit the study of a large population
without undue cost in time or energy Reliability compares scoring consistency
between examiners and the standard
9 Would permit the prompt detection of a shift in group conditions, measure, and also among groups of
for better or worse. examiners. Richmond et al reported
10 Should be valid through time (the index concentrating on, and being excellent intra-examiner and inter-
duly sensitive to, the basic defects of occlusal disorder, rather than examiner reliability with intraclass
to the symptoms of developmental changes) correlation coefficients of R> 0.95
and R=0.91 respectively.15 A study
that looked at inter-examiner agreement
between two examiners reported an
traits that were thought to be important malocclusion. Pre-treatment and post- intraclass correlation coefficient of 0.96.
in assessing malocclusion. Each set treatment study models are scored and There was no bias between the two
of models was projected onto four the difference between the scores reflects examiners.21 Another study involved
screens so that each examiner was able the degree of improvement and the ten examiners PAR scoring 206 study
to assess each case simultaneously. success of the treatment. A score of zero models; this reported a kappa score for
The scores that were derived from this represents an ideal occlusion and in inter-examiner reliability of 0.831 and
process were inputted into a database general the higher the score, the intra-examiner reliability of 0.877.22
to allow rapid multiple examiner more extensive the malocclusion.
comparisons.15 The PAR index has also been found to
Validity and reliability compare favourably with the Summers’
Each feature that deviates from the Validity describes the ability of an index Occlusal Index23 and correlates highly
ideal occlusion (all anatomical contact to measure accurately what it purports with orthodontists’ perception of
points adjacent, good interdigitation to measure.17 Validation of the PAR orthodontic treatment need.24
between posterior teeth and non- index was carried out by a panel of
excessive overjet/overbite) is allocated 74 examiners (including 22 consultant Table 2 shows the full PAR index together
a score and these are combined to give orthodontists, 22 specialist orthodontists, with the weightings. The PAR scoring
a total that represents the degree of 15 general dental practitioners, 11 sheet (see Figure 1; available from the

VOL. 5 NO. 4 WINTER 2016 29

 AN OVERVIEW OF THE PEER ASSESSMENT RATING (PAR)
INDEX FOR PRIMARY DENTAL CARE PRACTITIONERS

TABLE 2

THE PAR INDEX

COMPONENT SCORE DISPLACEMENT WEIGHTING

Contact point displacement
0 0 to 1mm
Upper
1 1.1 to 2mm
and lower
1 labial 2 2.1 to 4mm 1
segment
3 4.1 to 8mm
alignment
4 Greater than 8mm
5 Impacted (space between adjacent teeth is less than or equal to 4mm)
Anterio-posterior Transverse Vertical
0 Good interdigitation No crossbite No posterior open bite
1 Less than one half unit Crossbite tendency Posterior open bite of
from full interdigitation more than 2mm and
on at least two teeth
Buccal
2 2 One half unit Single tooth in crossbite 1
occlusion
discrepancy on any tooth
3 Greater than one tooth
in crossbite
4 Greater than one tooth
in scissor bite
Overjet Reverse overjet
0 0 to 3mm No anterior teeth in crossbite
1 3.1 to 5mm One tooth or more edge to edge
3 Overjet 2 5.1 to 7mm Single tooth in crossbite 6

3 7.1 to 9mm Two teeth in crossbite

4 Greater than 9mm Greater than two teeth
in crossbite
Overbite Open Bite
0 Less than one third coverage of the No open bite
lower incisor
1 Greater than one third but less than two Less than or equal to 1mm
thirds coverage of the lower incisor
4 Overbite 2
2 Greater than two thirds coverage of the 1.1 to 2mm
lower incisor
3 Greater than or equal to full coverage of 2.1 to 4mm
the lower incisors
4 Greater than 4mm
Centreline
0 Coincident or up to one quarter width of the lower incisor
5 Centreline 4
1 One quarter to one half width of the lower incisor
2 Greater than one half width of the lower incisor

30 P R I M A R Y D E N TA L J O U R N A L
 FIGURE 1

PAR SCORING SHEET

NAME

PRE-TREATMENT DATE

UN-WEIGHED WEIGHED
PAR COMPONENTS RIGHT LEFT
TOTAL TOTAL

Upper anterior segments 3-2 2-1 1-1 1-2 2-3 X1

Lower anterior segments 3-2 2-1 1-1 1-2 2-3 X1

Buccal occlusion Antero-posterior Right Left X1

 Transverse Right Left X1

Vertical Right Left X1

Overjet Positive Negative X6

Overbite Overbite Open Bite X2

Centre Line X4

 TOTAL

POST-TREATMENT DATE

UN-WEIGHED WEIGHED
PAR COMPONENTS RIGHT LEFT
TOTAL TOTAL

Upper anterior segments 3-2 2-1 1-1 1-2 2-3 X1

Lower anterior segments 3-2 2-1 1-1 1-2 2-3 X1

Buccal occlusion Antero-posterior Right Left X1

 Transverse Right Left X1

Vertical Right Left X1

Overjet Positive Negative X6

Overbite Overbite Open Bite X2

Centre Line X4

 TOTAL

ASSESSMENT OF OUTCOME

PAR SCORE IMPROVEMENT

Change in PAR score Greatly improved

% change in PAR score Improved

Worse or no different

VOL. 5 NO. 4 WINTER 2016 31

 AN OVERVIEW OF THE PEER ASSESSMENT RATING (PAR)
INDEX FOR PRIMARY DENTAL CARE PRACTITIONERS

FIGURE 2

THE PAR RULER

British Orthodontic Society website) and
PAR ruler (see Figure 2; Ortho-Care UK
Ltd, Saltaire, West Yorkshire) have been
developed to assist in PAR scoring.15
Table 3 gives a guide to the shorthand
used on the ruler.

The PAR index components

1 Upper and lower anterior teeth
Anomalies of the upper and lower
anterior teeth (crowding, spacing
and impacted teeth) are recorded by
measuring contact point displacement
and the greater this is, the greater the
score (see Figure 3). This is recorded as
the shortest distance between the contact Figure 3: Using the PAR ruler to measure
points of adjacent teeth parallel to the contact point displacement between the
occlusal plane. maxillary central incisors

Contact point displacements between

deciduous teeth, or between deciduous
teeth and permanent teeth, are not
recorded and contact points involving
poorly proportioned restorative work
or spaces that are to be filled by a
prosthetic replacement are not
recorded.

Spacing resulting from extraction,

agenesis or avulsion is recorded if

TABLE 3

PAR RULER SHORTHAND

Figure 4: Using the PAR ruler
Ant Anterior to assess overjet
dis Discrepancy
e to e Edge to edge
FTC Full tooth coverage
Openb Openbite
Post Posterior
Pt Point
sb Scissor bite
t Tooth
tend Tendency
Xbite / xb Crossbite
> Greater than

< Less than Figure 5: The centreline is assessed

in relation to the lower centreline

32 P R I M A R Y D E N TA L J O U R N A L
closing the space, but is not recorded
if opening the space, unless it is less
than or equal to 4mm.
A tooth is recorded as impacted if the
space between the adjacent teeth is
less than or equal to 4mm. In cases
where there is potential crowding in the
mixed dentition, the space deficiency is
calculated using average mesio-distal
widths. If the remaining space for an
unerupted tooth is 4mm or less an
impaction is recorded.
2 Buccal occlusion
The buccal occlusion is scored in all
three planes of space and is recorded
from the canine to the terminal molar
for the anterio-posterior and vertical
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dimension but the canine is excluded
from the transverse dimension.
3 Overjet
The overjet is measured from the
most prominent incisor. The ruler is
held parallel with the occlusal plane
and radial to the line of the arch (see
Figure 4).
The overjet is assessed from the side,
as an incorrect score can be recorded
if doing so from the front. If the incisor
in question lies on the line itself the
lower score is recorded.
In cases where there are incisors and
canines in crossbite in addition to a
positive overjet the scores are added
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 AN OVERVIEW OF THE PEER ASSESSMENT RATING (PAR)
INDEX FOR PRIMARY DENTAL CARE PRACTITIONERS

FIGURE 6 together. An increased overjet that 2 Percentage reduction in PAR score

has resulted from poor restorative
HOW TO CALCULATE work is not recorded.
THE PERCENTAGE
4 Overbite and open bite
REDUCTION IN The overbite is measured in relation
PAR SCORE to coverage of the lower incisors and
is recorded from the lower incisor
Pre-treatment PAR score 37
with greatest coverage by an upper
Post-treatment PAR score 1
incisor. For an open bite, the greatest
Reduction in PAR score 36
space between the incisal edges is
Percentage reduction 36 x 100
recorded. In cases where there is
37 = 97%
both an overbite and open bite, both
scores are recorded.
5 Centreline
The centreline discrepancy is measured
in relation to the lower central incisors
(see Figure 5). If a lower incisor has
been extracted, an estimate of the
lower centreline is made.
Interpreting the data
There are essentially three ways of
interpreting the PAR scores.15,25,26
Richmond et al considered a PAR
score of 10 or less to be acceptable
alignment and occlusion and a PAR
score of five or less to be an almost-
ideal occlusion.15
1 Point reduction in PAR score
For example, from a pre-treatment score
of 37 to a post-treatment score of one,
the reduction would be 36.
To deduce the percentage reduction
in PAR score, the reduction in PAR score
is divided by the pre-treatment PAR score
and multiplied by 100 (see Figure 6).
This method uses four categories
of improvement:
• Great improvement: 70% to 100%
•  Improvement: 50% to 69%
• Little improvement: 30% to 49%
•  No improvement: <30%
3 Plotting the PAR score
on a nomogram
The outcome can also be found by
plotting the PAR score on a nomogram,
a two-dimensional graphical calculating
diagram to permit the approximate
graphical computation of a mathematical
function. The PAR nomogram was
developed using discriminate analysis
as part of the validation exercise.
The pre-treatment PAR score is plotted
on the x-axis against the post-treatment
PAR score on the y-axis (see example
in Figure 7). This method uses three
categories of improvement:
•  Greatly improved: A reduction 22
points or more (a case with a pre-
treatment score of 22 PAR points or
less cannot be classed as ‘greatly
improved’ as it was not sufficiently
severe prior to treatment)
• Improved: A reduction of at least 30%
•  Worse or no different: A reduction
of less than 30%

REFERENCES
1 Arruda AO. Occlusal indexes as
judged by subjective opinions.
Am J Orthod Dentofacial Orthop
2008;134(5):671-675.
2 Summers CJ. The occlusal index: a
system for identifying and scoring
occlusal disorders. Am J Orthod
1971;59(6):552–566.
3 Pickering EA, Vig P. The
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1975;2(1):47–51.
4 Elderton RJ, Clark JD. Orthodontic
treatment in the General Dental
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5 Elderton RJ, Clark JD. An
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in the General Dental Service
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1 malocclusions. Br J Orthod
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6 Myrberg N, Thilander B. An
evaluation of the duration and
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7 Eismann D. A method of evaluating
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Trans Eur Orthod Soc 1974;
223–232.
8 Gottlieb EL. Grading your
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Clin Orthod 1975;9(3):143-154.
9 Berg R. Post-retention analysis of
treatment problems and failures in
264 consecutively treated cases.
Eur J Orthod 1979;1(1): 55-68.
10 Eismann D. Reliable assessment of
morphological changes results from
orthodontic treatment. Eur J
Orthod 1980;2(1):19-25.
11 Berg R, Fredlund A. Evaluation
of orthodontic treatment results.
Eur J Orthod 1981;3(3):181-185.
12 World Health Organization.
An international methodology
for epidemiological studies
of oral disease. Manual No.
5: Epidemiological studies of
periodontal disease. Geneva:
World Health Organization; 1966.
13 Summers CJ. Tests of validity of
indices of occlusion. Am J Orthod
1972;62:(4):428-429.
14 Tang EL, Wei SH. Recording
and measuring malocclusion:
A review of the literature. Am
J Orthod Dentofacial Orthop
1993;103:(4):344-351.
15 Richmond S, Shaw WC, O’Brien
KD, Buchanan IB, Jones R, Stephens
CD, Roberts CT, Andrews M.
The development of the PAR
index (Peer Assessment Rating):
reliability and validity. Eur J Orthod
1992;14(2):125-139.
16 British Orthodontic Standards
Working Party. Second report.
Br J Orthod 1986;13:165-173.
17 Carlos JP. Evaluation of indices
of malocclusion. Int Dent J
1970;20(4):606-617.
18 Shaw WC, Richmond S, O’Brien
KD. The use of occlusal indices:
a European perspective. Am
J Orthod Dentofacial Orthop
1995;107(1):1-10.
19 Grainger RM. Orthodontic treatment
priority index. Vital Health Stat
1967;2(25):1-49.
20 Salzmann JA. Handicapping

34 P R I M A R Y D E N TA L J O U R N A L
 FIGURE 7

THE PAR NOMOGRAM

45 The PAR
Nomogram.
40
Pre-treatment
35 PAR scores are
Worse or No Different plotted against
Post Treatment PAR

30
post-treatment
25 PAR scores to
Greatly Improved determine the
20 category of
Improved improvement for
15
each case. In
10 this example, 50
cases have been
5
plotted on the
0 nomogram.
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70
Pre Treatment PAR

The index is intended to look at the
outcomes for a group of patients rather
than an individual as the index may
not fully represent the result obtained
in all cases. Evaluating treatments that
began consecutively should give a better
indication of the treatment provided,
and treatments that were not completed
should also be included.26
Calibration
Dental professionals, as well as non-
dental personnel,27 can be trained to use
the PAR index to assess cases to a high
degree of reliability. While not currently
a mandatory requirement, in the
interests of accuracy and reproducibility,
calibration in the use of the index is
strongly recommended.28 Revalidation
by means of a refresher course is also
advisable.29 A national database of
personnel calibrated in the use of the
PAR index is available from the British
Orthodontic Society (BOS) website.30
However, even with calibration,
personal biases concerning severity or
differences in ability or experience mean
that there is no guarantee that results
will be comparable.31
Primary care orthodontics
More than 150,000 patients receive
orthodontic treatment under the NHS
each year and around 130,000 of
those are in primary care. It is a
statutory requirement of the NHS
orthodontic contract for providers
to monitor treatment outcomes for
20 cases plus 10% of the remainder

malocclusion assessment to establish
treatment priority. Am J Orthod
1968;54(10):749-765.
21 Birkeland K, Bøe OE, Wisth PJ.
Subjective assessment of dental and
psychosocial effects of orthodontic
treatment. J Orofac Orthop
1997;58(1):44-61.
22 Pangrazio-Kulbersh V, Kaczynski
R, Shunock, M. Early treatment
outcome assessed by the Peer
Assessment Rating index. Am
J Orthod Dentofacial Orthop
1999;115(5):544-550.
23 Buchanan IB, Shaw WC, Richmond
S, O’Brien KD, Andrews M. A
comparison of the reliability and
validity of the PAR Index and
Summers’ Occlusal Index. Eur J
Orthod 1993;15(1):27-31.
24 McGorray SP, Wheeler TT, Keeling
SD, Yurkiewicz L, Taylor MG, King
GJ. Evaluation of orthodontists’
perception of treatment need and
the peer assessment rating
(PAR) index. Angle Orthod
1999;69(4):325-333.
25 Richmond S, Shaw WC, Roberts
CT, Andrews M. The PAR index
(Peer Assessment Rating): methods
to determine outcome of orthodontic
treatment in terms of improvement
and standards. Eur J Orthod
1992;14(3):180-187.
26 Richmond S. Evaluating Effective
Orthodontic Care, 1st ed. Cardiff:
FIRST Numerics Ltd; 2005. p38-39.
27 Richmond S, Turbill EA, Andrews
M. Calibration of non-dental
and dental personnel in the use
of the PAR Index. Br J Orthod
1993;20(3):231-234.
28 PAR scoring for NHS providers.
British Orthodontic Society.
Available at: www.bos.org.
uk/Professionals-Members/
Research-Audit/Quality-Assurance-
in-Orthodontics/The-Peer-Assessment-
Rating-PAR-index/PAR-scoring-for-
NHS-providers
29 The Peer Assessment Rating
(PAR) index. British Orthodontic
Society. Available at: www.bos.
org.uk/Professionals-Members/
Research-Audit/Quality-Assurance-in-
Orthodontics/The-Peer-Assessment-
Rating-PAR-index.
30 Directory of calibrated PAR
scorers. British Orthodontic
Society. Available at: www.bos.
org.uk/Professionals-Members/
Research-Audit/Quality-Assurance-in-
Orthodontics/The-Peer-Assessment-
Rating-PAR-index/Directory-of-
calibrated-PAR-scorers.
31 Roberts CT, Richmond, S. The design
and analysis of reliability studies for
the use of epidemiological and audit
indices in orthodontics. Br J Orthod
1997;24(2):139-147.
32 Quality Assurance in NHS
Primary Care Orthodontics. British
Orthodontic Society. Available at:
www.bos.org.uk/Professionals-
Members/Research-Audit/
Quality-Assurance-in-Orthodontics/
Quality-Assurance-in-NHS-Primary-
Care-Orthodontics.
33 Hamdan AM, Rock WP. An
appraisal of the Peer Assessment
Rating (PAR) Index and a suggested
new weighting system. Eur J Orthod
1999;21(2):181-192.
34 DeGuzman L, Bahiraei BS,

VOL. 5 NO. 4 WINTER 2016 35

 AN OVERVIEW OF THE PEER ASSESSMENT RATING (PAR)
INDEX FOR PRIMARY DENTAL CARE PRACTITIONERS

of cases per year, using the PAR

TABLE 4
index.28,32 To minimise bias and
inaccuracy, it has been suggested PAR INDEX COMPONENT WEIGHTINGS DETERMINED
that 20 consecutive cases are chosen
USING OPINIONS OF BRITISH AND AMERICAN
and assessed by an independent third
party calibrated in the use of the index.32 ORTHODONTISTS
UK US
Limitations
Hamdan and Rock reported concerns Richmond et al. DeGuzman et al.
regarding the weightings, especially 199215 199534
those assigned to overjet and overbite.33 Upper labial segment alignment 1 1
Using a single weighting system for
all malocclusions can cause difficulties Lower labial segment alignment 1 0
because the importance of different Buccal occlusion 1 2
features can vary in different classes
of malocclusion.33 DeGuzman et al Overjet 6 5
proposed a new set of weightings34
Overbite 2 3
(see Table 4) but these have not
been widely adopted in the UK. Centreline 4 3

Studies have reported that the index

can be unduly harsh in cases with
limited aims35 and insensitive when
assessing certain aspects of residual
treatment such as unfavourable incisor
inclinations, remaining extraction
spaces and rotations.36 Others have
stated that it does not account for
iatrogenic conditions such as apical
root resorption, enamel lesions and
marginal bone loss21,37 and overlooks
periodontal health, tooth angulation,
patient compliance and patient
satisfaction.38 Its use for mixed
dentition cases has also been
questioned.39
Applications
Since its introduction, much research
utilising the PAR index as a measure
of orthodontic treatment efficiency has
been published. Studies have used the
index to evaluate treatment provided
by general dental services in both
England and Wales40-45 and Scotland.46
O’Brien et al reported a mean PAR
score reduction of 68% for 1,630 cases
treated by the hospital orthodontic
service in England and Wales47 while
Richmond and Andrews reported a
mean PAR score reduction of 78% for
200 Norwegian cases.48 The index
has also been used to compare outcomes
between US postgraduate orthodontic
clinics.49
Dyken et al38 reported a significant
association between a higher pre-
treatment PAR score and a greater
percentage reduction in PAR score
with longer treatment durations
while Peppers et al used the index to
determine that variations in primary
attending clinician coverage frequency
in a graduate clinic did not lengthen
or reduce the quality of orthodontic
treatment.50

Vig KWL, Vig PS, Weyant RJ,
O’Brien K. The validation of the
Peer Assessment Rating index for
malocclusion severity and treatment
difficulty. Am J Orthod Dentofacial
Orthop. 1995;107:172-176.
35 Kerr WJ, Buchanan IB, McColl JH.
Use of the PAR index in assessing
the effectiveness of removable
orthodontic appliances. Br J Orthod
1993;20(4):351-357.
36 Hinman C. The Dental Practice
Board. Orthodontics--the current
status. Br J Orthod 1995;
22(3):287-290.
37 Linge L, Linge BO. Patient
characteristics and treatment
variables associated with root
resorption during orthodontic
treatment. Am J Orthod Dentofacial
Orthop 1991;99(1):35-43.
38 Dyken RA, Sadowsky PL, Hurst D.
Orthodontic Outcomes Assessment
Using the Peer Assessment
Rating Index. Angle Orthod
2001;71(3):164-169.
39 Fox NA. The first 100 cases: a
personal audit of orthodontic
treatment assessed by the PAR (peer
assessment rating) index. Br Dent J
1993;174(8):290-297.
40 Richmond S, Andrews M, Roberts
CT. The provision of orthodontic
care in the general dental services
of England and Wales: extraction
patterns, treatment duration,
appliance types and standards. Br J
Orthod 1993; 20(4): 345-350.
41 Turbill EA, Richmond S, Andrews
M. A preliminary comparison of
the DPB’s grading of completed
orthodontic cases with the PAR
Index. Br J Orthod 1994;21(3):
279-285.
42 Turbill EA, Richmond S, Wright
JL. Assessment of General Dental
Services orthodontic standards: the
Dental Practice Board’s gradings
compared to PAR and IOTN. Br J
Orthod 1996;23(3): 211-220.
43 Turbill, EA, Richmond S, Wright JL.
A critical assessment of orthodontic
standards in England and Wales
(1990-1991) in relation to changes
in prior approval. Br J Orthod
1996;23(3):221-228.
44 Turbill EA, Richmond S. Wright JL. A
critical assessment of high-earning
orthodontists in the General Dental
Services of England and Wales
(1990-1991). Br J Orthod 1998;
25(1):47-54.
45 Turbill EA, Richmond S. Wright JL.
A closer look at General Dental
Service orthodontics in England
and Wales. II: What determines
appliance selection? Br Dent J
1999;187(5): 271-274.
46 Teh LH, Kerr WJ, McColl JH.
Orthodontic treatment with fixed
appliances in the General Dental
Service in Scotland. J Orthod
2000;27(2):175-180.
47 O’Brien KD, Shaw WC, Roberts
CT. The use of occlusal indices
in assessing the provision of
orthodontic treatment by the hospital
orthodontic service of England
and Wales. Br J Orthod
1993;20:(1):25-35.
48 Richmond S, Andrews M.
Orthodontic treatment standards
in Norway. Eur J Orthod
1993;15(1):7-15.

36 P R I M A R Y D E N TA L J O U R N A L
A greater percentage reduction in
PAR score has been reported for
patients treated with fixed appliances
than with removable appliances35,39,47
and the index has been used successfully
to evaluate cases involving orthognathic
surgery.51,52
Research has also supported the use of
digital study models for PAR scoring.53, 54
Comparisons with
other indices
Fox et al55 examined the relationships
between the PAR index, the Index of
Orthodontic Treatment Need (IOTN)56
and the Index of Complexity, Outcome,
and Need (ICON)57 and reported that
ICON could effectively replace the PAR
Index and IOTN. A study comparing the
PAR Index, ICON, the American Board
of Orthodontics objective grading system
(ABO-OGS) and the dental aesthetic
index (DAI) and also concluded that
ICON could supplant the PAR Index, as
well as the ABO-OGS and the DAI.58
Bergstrom and Halling59 reported
that PAR was unsuited as a measure
of orthodontic treatment need since
it ‘estimates deviations from an ideal
occlusion and the other indices evaluate
treatment need’ after comparing PAR
with two Swedish indices of treatment
need (The modified Indication Index
and The modified Index of the Swedish
Medical Health Board) but Firestone
et al reported that PAR was an
excellent predictor of orthodontic
treatment need.60
Conclusion
While it isn’t without its limitations,
the PAR index is a reliable and
valid method of assessing orthodontic
treatment outcomes. Despite the
development of ICON, which
could effectively supercede it, the
PAR index remains the most widely
accepted such tool and plays a vital
role in commissioning and monitoring
the quality of NHS orthodontic
treatment provision.
The PAR index relies on calibration
to ensure standardisation. This paper
is intended to serve as an introduction
to the PAR index and is not comparable
to a calibration course. Although not
currently a mandatory requirement,
it is strongly advised that those wishing
to provide accurate and reproducible
assessments using the index should
attend and pass an appropriate
calibration test.

49 Deguchi T, Honjo T, Fukunaga T,
Miyawaki S, Roberts WE, Takano-
Yamamoto T. Clinical assessment
of orthodontic outcomes with the
peer assessment rating, discrepancy
index, objective grading system, and
comprehensive clinical assessment.
Am J Orthod Dentofacial Orthop
2005;127(4):434-443.
50 Peppers EC, Leggitt VL, Caruso JM,
Neufeld R, Green J. The effect of
changes in primary attending doctor
coverage frequency on orthodontic
treatment time and results. Angle
Orthod. 2015;85:(6):1051-1056.
51 Templeton KM, Powell R, Moore
MB, Williams AC, Sandy JR.
Are the Peer Assessment Rating
Index and the Index of Treatment
Complexity, Outcome, and Need
suitable measures for orthognathic
outcomes? Eur J Orthod
2006;28(5):462-466.
52 O’Rourke N, Green J, Cox S.
An audit of occlusal outcomes in
orthognathic care in the Royal
London Hospital over 2 years.
Proceedings of the 28th British
Orthodontic Conference; 2014 Sep
18-20; Edinburgh, United Kingdom.
Page 58.
53 Mayers M, Firestone A, Rashid
R, Vigd KWL. Comparison of
peer assessment rating (PAR)
index scores of plaster and
computer-based digital models.
Am J Orthod Dentofacial Orthop.
2005;128(4):431-434.
54 Stevens DR, Flores-Mir C, Nebbe
B, Raboud DW, Heo G, Major
PW. Validity, reliability, and
reproducibility of plaster vs
digital study models: comparison
of peer assessment rating
and Bolton analysis and their
constituent measurements. Am
J Orthod Dentofacial Orthop
2006;129(6):794–803.
55 Fox NA, Daniels C, Gilgrass T.
A comparison of the Index of
Complexity Outcome and Need
(ICON) with the Peer Assessment
Rating (PAR) and the Index of
Orthodontic Treatment Need
(IOTN). Br Dent J 2002;193(4):
225-230.
56 Brook PH, Shaw WC. The
development of an index of
orthodontic treatment priority. Eur J
Orthod 1989;11(3):309–320.
57 Daniels C, Richmond S. The
development of the index of
complexity, outcome and need
(ICON) J Orthod 2000;27(2):
149-162.
58 Onyeaso CO, Begole EA.
Relationship between index of
complexity, outcome and need,
dental aesthetic index, peer
assessment rating index, and
American Board of Orthodontics
objective grading system. Am
J Orthod Dentofacial Orthop
2007;131(2):248-252.
59 Bergstrom K, Halling A. Comparison
of three indices in evaluation of
orthodontic treatment outcome. Acta
Odontol Scand 1997;55(1):36-43.
60 Firestone AR, Beck FM, Beglin FM,
Vig KW. Evaluation of the peer
assessment rating (PAR) index as an
index of orthodontic treatment need.
Am J Orthod Dentofacial Orthop
2002;122(5):463-469.

VOL. 5 NO. 4 WINTER 2016 37

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