Adherence in adult orthodontic settings: Understanding orthodontists’ predictors

INTRODUCTION

Orthodontic treatment is a way of straightening or moving teeth, to improve the appearance of the teeth and how they work. Orthodontic treatment necessitates several disciplinary activities and restrictions such as attending appointments, daily practice of good oral hygiene, and dietary restrictions. Different samples of orthodontic appliances are used to correct malocclusion, retrain muscles, and effect on growth (Elhussein and Sandler, 2018).^[1]

Psychological and behavioral aspects of patients play a significant role in non-adherence; it is crucial that patients must change their behavior and cooperate with clinicians/orthodontists to ensure positive outcomes of the treatment. The behavior of patients in the clinic is regarded as “compliance;” however, recently, it is termed as “adherence” (Tervonen et al., 2011).^[2] Orthodontists believe that factors such as personality traits, motivation for treatment, maintenance of oral hygiene, and communication between orthodontist and patient contribute to adherence (Eppright et al., 2014; Schäfer et al., 2015; Zotti et al., 2016).^[3-5] Poor adherence to orthodontic treatment leads a patient to several complications corresponding to decalcifications of the teeth, uncorrected malocclusion, negative psychological and social outcomes attributable to the appearance of their teeth and mouth, a prolonged course of treatment, premature treatment termination, wasted family and provider resources (Apajalahti and Peltola, 2007; Skidmore et al., 2006).^[6,7] Adherence to orthodontic treatment is essential to ensure the patient’s ultimate positive treatment outcome; since it depends on timing and completion of the orthodontic treatment. However, the previous research demonstrated that data related to adherence to orthodontic treatment are not encouraging; since, treatment termination reported in 43–50% patients due to poor adherence to treatment (Mandall et al., 2008; Martin et al., 2017).^[8,9]

It can be argued that non-adherence is not only related to attendance but also to several other factors. Since, poor adherence or non-adherence to the orthodontic treatment usually reflects in the form of poor oral hygiene, broken appliances, patients’ ability to cope with the experience of pain and discomfort during treatment, and non-compliance with wear of prescribed elastics or removable appliances (Crerand et al., 2019).^[10] It can be argued that non-adherence to the orthodontic treatment is not uniform throughout all the situations; rather, it can be situational-based. Patients might exhibit adherence based on the anticipated outcome. In some instances, patients might be adherent; however, in other instances, they might be non-adherent. Patients might follow appointments on a regular basis; however, they might not wear the appliances during the treatment duration. Hence, clinicians should always be alerted to fluctuations and prepared to take corrective actions. Accurate predictions by the orthodontists regarding the adherence by patients are crucial in executing corrective strategy. Hence, it is essential to understand the orthodontist’s predictors regarding adherence (Al Shammary et al., 2017).^[11] Further, these predictors can be implemented in a calibrated manner based on their importance for the measurement of patient adherence in the orthodontic setting. Several direct and indirect methods are available for estimating a patient’s adherence to the orthodontic setting. However, these methods are associated with limitations such as variable reliability and applicability due to variable orthodontic settings (Bos et al., 2007; Cole, 2002).^[12,13]

The previous research demonstrated orthodontists’ interpretation of adherence of patients in the orthodontic setting which explored factors such as oral hygiene and appointment keeping as the indicators of adherence. However, these indicators cannot be generalized because these studies were conducted on the young population with a small number of participants. In the previous studies, either open- or closed-type questions were asked of the orthodontists (Bos et al., 2007; Al Shammary et al., 2015).^[12,14] Moreover, studies evaluating orthodontist’s predictors of adherence to orthodontic treatment in Kingdom of Saudi Arabia (KSA) were not conducted.

This study aims to explore the predictors of orthodontists for adherence of adult patients in the orthodontic settings. Attention is given to rank these predictors in terms of importance and frequency of actual use, as stated by the orthodontist.

MATERIAL AND METHODS

RESULTS

DISCUSSION

In this study, a survey was conducted to understand adherence predictors in orthodontic settings in terms of its importance and frequency of use in daily practice. In addition to these question-based factors, other relevant factors were extracted through presenting open-ended questions to the participants.

The majority (71%) of the orthodontists reported treatment termination in <10% of cases and 29% of orthodontists reported treatment termination in 11–30% of patients due to poor adherence to the treatment (Crerand et al., 2019).^[10] Mehra et al. (1998)^[15] reported that 95% of orthodontists reported treatment termination in <5% of the patients, while 5% of orthodontists reported treatment termination in 5–10% of the patients. Adherence to treatment is a crucial factor in cases of prolonged treatment. However, there is no consensus to define prolonged treatment in an orthodontic setting. In some cases, minimum 3 months of treatment and in a few cases, 1-year treatment, beyond the agreed on end of treatment is considered as prolonged treatment. Research demonstrated that family domain and health-care system factors also significantly influence adherence. In the family domain, factors such as family members’ mental health, treatment motivation, supervision of care by the family members, coping skills, and awareness of the treatment plan have a substantial impact on adherence. Hence, it is essential to target interventions to family members’ motivation and behavior. Motivation by family members can be exemplified by monitoring oral hygiene of patients by the family members. Health-care system-related factors include communication between the patient and health-care providers which promotes change in the behavior of patient and the family members. Health-care system-related factor targets orthodontic education program and dietary instructions (Wysocka et al., 2014; Crerand et al., 2019).^[16,10]

In the present study, three factors were rated with the highest importance which includes, “The patient maintains excellent oral hygiene,” “The patient cooperates with the use of removable dental appliances (such as retainers) and/or elastics,” and “The patient keeps appointments.” However, a minimal number of participants did not give importance to these factors. These insignificant numbers of participants would not affect the outcome of the study; however, it is worthwhile to assess the reason behind not giving importance to these factors by these small number of participants. It is obligatory that orthodontists should practice the factors of adherence to which they give more importance. However, in actual practice, these orthodontists practice only one factor, “The patient keeps appointments.” It can be argued that participants gave the least importance to this factor out of the three factors with more importance. Nevertheless, orthodontists implemented this factor more frequently in comparison to any other factor. From the obtained results, it can be argued that there was partial agreement between the importance and practice of orthodontists in assessing patient adherence. Orthodontists practiced only one factor in assessing patient adherence; though, the other two factors are also deemed important. Some of the findings from this study were consistent with factors reported in the previous studies. Mehra et al. (1998) and Slakter et al., (1980)^[15,17] reported factors such as maintaining regular appointments, good oral hygiene, and adequate use of appliances, as relevant factors for the adherence of patients in orthodontic settings.

For few of the factors studied in this study, there was no agreement between the level of importance and its implementation in actual clinical practice. For factors such as “The patient has distorted or damaged wires and/or loose bands” and “The patient maintains excellent oral hygiene,” orthodontists mentioned neither “Not so important” nor “Not at all important.” However, a realistic number of participants employed it rarely in actual practice. Orthodontists demonstrated a positive correlation among factors with the lowest importance and least employed in the actual practice. Orthodontists demonstrated the lowest scores in terms of both importance and frequency for factors such as, “The patient speaks of personal problems or demonstrates such problems,” “The patient complains about treatment procedures (i.e., procedures performed by the orthodontist),” “The patient complains about having to wear braces,” and “The patient has a negative view or perception of their malocclusion.” It reflects, orthodontists are not willing to implement the adherence factor in actual practice, if they do not feel it as important factor. Out of these four factors, Slakter et al. (1980),^[17] stated “The patient speaks of personal problems or demonstrates such problems” as adequate measure of adherence in orthodontic setting.

Through open-ended questions, different predictors of adherence were explored, which include oral hygiene, cost, patient-related factors, time, and integrative and cooperative approach in treatment. These predictors comprise different factors which were coded under respective predictors. Among these, “oral hygiene” and “integrative and cooperative approach in treatment” were stated as the most important factors by the orthodontists. Moreover, “oral hygiene” and “patient-related factors” were more frequently employed adherence measures by the orthodontists. There was not much difference between “oral hygiene” and “patient-related factors” in terms of its importance. Hence, these two factors can be considered as most acceptable predictors stated by the orthodontists through the open-ended questions. The previous research also demonstrated that “oral hygiene” and “keeping appointments” are most important predictors for patient adherence; however, these were not most frequently used by the orthodontists (Martin et al., 2005; Brattström et al., 1991).^[18,19] However, authors argued that the lack of evidence for the frequent use of these predictors might be due to improper record keeping of these predictors during actual practice. Most of the predictors reported during open questions were stated for the 1^st time in adult’s orthodontic setting. Hence, its importance and frequency of use should be revalidated in a study comprising structured questions.

CONCLUSION

“The patient maintains excellent oral hygiene” was regarded as the most important predictor by the orthodontists. “The patient keeps appointments” was regarded as the most frequently used predictor by orthodontists. In open-ended questions, orthodontists highlighted “Oral hygiene” and “Integrative and cooperative approach in treatment” as the most important predictors for adherence in an orthodontic setting. Furthermore, “Oral hygiene” and “Patient-related factors” were reported as the most frequently used predictors through the open-ended questions.