Patient cooperation in wearing orthodontic headgear Edward J. Clemmer, Ph.D., and Eugene W. Hayes, D.D.S., MS. St. Louis, MO.
T
he cooperative orthodontic patient will wear headgear or elastics as directed, avoid or report appliance breakage, follow instructions regarding oral hygiene and diet, and conform to office procedures and schedules.‘, ‘Z lx, “+ *’ Successful orthodontic treatment requires the patient’s cooperation. Jarabak’s”’ observation is frequently reiterated: Lack of patient cooperation can destroy the best treatment planning and the most promising treatment mechanics.‘, 8, 27 There are a number of ways to deal with the problem of patient noncooperation. Some orthodontists have proposed that appliances be “tied in”2 or that treatment mechanics be developed which do not require active patient participation.5 On the other hand, the orthodontist can attempt to motivate the patient.i3s lx Sometimes, unfortunately, the orthodontist may become too engrossed in treatment mechanics to motivate patients properly . ‘* 17, I9 However, patients can be instructed in ways which provide a rationale for cooperative behaviors. ‘, 31 And undesirable patient behaviors can be modified or new habits can be learned.“, l*, i5. 3R,34 Moreover, through some understanding of the nature of patient cooperation in orthodontics, it would be possible (1) to identify patients who would likely be more or less cooperative and (2) to provide some rationale for promoting cooperation in patients. This is the purpose of the present study. Provided that there is some measurable behavioral criterion of patient cooperation, it would be possible to show how selected variables relate to cooperation and other independent factors. This would be possible even with a small sample of patients, provided that the sample contains both cooperators and noncooperators. Specifically, the present study defined cooperation as the actual hours of headgear wear relative to the directives of the orthodontist. Cooperation in wearing headgear was related to the most relevant measures suggested by the review of the literature. Review of the literature Since the decision to seek treatment often originates with parents rather than with patients, 3, ‘. lo* ” the patient may not be disposed to cooperate. The patient’s primary motive for seeking treatment may be an appreciation of “straight teeth.“27 Accordingly, Lewit and Virolainen23 determined that the best predictor of desire for orthodontic treatment in 129 children was their self-perceived orthodontic condition. In a study by Lewis and Brown,22 74 of 100 children stated that they continued to wear orthodontic appliances because they wanted to “look better” or to “have straight teeth.” However, patient From the Department of Orthodontics, Saint Louis University ooO2-9416/79/050517+08$00.80/0
0
1979 The C.V. Mosby Co.
517
57 8
Clemmer and HU.WS
self-perceptions or oral self-images have very little relationship to measurable malocclusion.*‘, *‘, *’ Unless malocclusion is severe, objective malocclusion is related neither to the desire to seek treatment4* ~3, 27 nor to ratings of patient cooperation.“A Some orthodontists have attempted to develop some readily accessible criteria for identifying cooperative patients. Stambach and Kaplan2x employed sociologic descriptions to classify their recollections of cooperation for 132 “excellent” and 126 “average” patients. Excellent patients tended to be female Christians with working-class fathers. Broekma# cites greater cooperation among girls, especially those over 14 years of age. However, many studies indicate that the best cooperation ratings are assigned to preadolescent patients. ‘* 2’. a2Even though Crawford” found some relationship between age and ratings of cooperation, it was not possible to predict those ratings in a beginning orthodontic patient. McDonald ” found no relationship between age and ratings of cooperation. For the most part, efforts to relate ratings of cooperation to the patient’s personality have been unsuccessful. In Allan and Hodgson’s’ study, none of the individual items on Gough’s’” Adjective Check List identified more highly rated cooperators. Gabriel’s’” posttreatment estimate of motivation for 67 patients was minimally predicted (8.4 percent of variance) from a set of items selected from the California Test of Personality (a measure of personal-social adjustment). However, McDonaldz4 found the California Test of Personality to be related to ratings of patient cooperation, as did Gossett (cited in Starnbach and KaplanzH). Other studies have used one of several inventories for assessing a patient’s “locus of control.” All of the inventories place a person on a continuum relative to internal-external locus of control. Persons with an internal locus of control feel more strongly that what they do is likely to affect what happens to them, while those with an external locus of control perceive themselves as hapless victims of uncontrollable circumstances and manipulations. Lewit and Virolainen 23found a greater desire for orthodontic treatment among patients with a more internal locus of control, but only for middle-class children with low scores on both test anxiety and social desirability. Also, Crawford9 found that locus of control was associated in an unspecified manner with ratings of patient cooperation. Consistently, ratings of patient cooperation seem to be related to the patient’s school cooperation. Kreit, Burstone, and Delman,2’ who administered a 287-question personality inventory to 1,386 patients rated on cooperation, found that uncooperative patients admitted more often that their parents did not think their grades in school were high enough. Also, cooperative patients asserted more often that they always did what their teachers told them to do. In fact, research by Herren, Baumann-Rufer, Demisch. and Berg’” and by Bums’ shows that teachers give higher ratings of school cooperation to orthodontic patients who receive higher ratings of orthodontic cooperation. These findings suggest that patient cooperation reflects the mature attitude of a generalized personality trait. Ratings of patient cooperation may or may not reflect actual patient behavior. Typically, the predictive ability of the various studies is minimal because ratings made at some distance from actual observations of patients and based on unrefined global criteria are subject to considerable imprecision and experimenter bias. By contrast, in parallel research from our clinic, Swetlik30 employed the specific behavioral criterion of cooperation-hours of headgear wear. While Swetlik did not find a relationship between headgear wear and a measure of locus of control, he did indicate that patients who were more
Volume 15 Number 5
Patient cooperation in wearing headgear
519
Table I. Patientdescriptionsof clinic cooperationcharacterizedby the treating residentas true, mostly true, neutral, mostly false, or false I. 2. 3. 4. 5. 6. 7. 8. 9. IO.
Your patient is always on time. Your patient is an excellent cooperator. Your patient is interested and attentive to your instructions. You and your patient have excellent rapport with each other. Your patient can be trusted to do exactly what he or she is told. Your patient showed great interest in his or her orthodontic treatment. Your patient could be classified as an ideal patient. Your patient would try exceptionally hard to please you. Your patient does not have to be constantly reminded to do his or her part. Your patient complained a lot. *
*Higher numerical ratings were assigned to false responses.
concerned about how they were regarded by others would initially resist headgear wear but were more likely to wear headgear 9 weeks later. The present study, as Jaffe’? and Stricker” have suggested, addresses the need for sound behavioral research to tackle orthodontic problems such as patient cooperation. Method and materials Subjects. Twenty Caucasian clinic patients were in their first year of edgewise treatment by residents of the Saint Louis University Department of Orthodontics. There were nine girls and eleven boys. The mean age of both girls and boys was 13.8 years, but the age range was more variable for girls ( 11 to 17 years) than for boys (11 to 15 years). Respective standard deviations were 1.92 and 1.25 years. Patients currently wearing cervical headgear were selected if their treatment plan called for continued headgear wear for 12 to 14 hours per day for at least three 2- to 3-week periods. Including cooperators and noncooperators, patients over-all averaged 55.8 percent of their recommended hours of headgear wear. Actual headgear wear averaged 7.43 hours per day, which was nearly 2 hours less than Swetlik’s30 observation of 9.28 hours of daily headgear wear. Overt measures. Included as variables were the sex and age of the patient. The hours of suggested headgear wear (hours advised) were recorded. After the final observation period, patients stated in hours what they thought their resident’s directives had been (reporting directions) and how many hours per day they thought they had worn their headgear (reporting headgear wear). Cooperation measures. For each 2-to 3-week period, headgear wear in hours was measured covertly by an Aledyne timerz5 incorporated into the headgear’s cervical-pull neck strap. Through pretesting, the accuracy of all the timers was determined to fall within 3 percent above or below real time. The percentage of actual headgear wear was determined relative to both the hours-per-day directives of the treating resident (objective cooperation) and the patient’s statement of those directives (subjective cooperation). The treating resident evaluated the patient’s cooperation (clinic cooperation) as the mean of ten questions rated on a five-point scale (Table I). A schoolteacher considered by the patient to be impartial also rated the patient’s cooperation in school (school cooperation) as the mean of fifteen items rated on a five-point scale.16 Malocclusion. Three clinical professors of orthodontics at Saint Louis University
Table partly
II. Patient true.
mostly
self-descriptions true,
I. 2. 3. 4.
rat&
or completely
as complrteiy
false.
mostly
false.
partly
i’alsc and
true
In general,.mv teeth are better than other people’s teeth. * My malocclusion was very bad before orthodontic treatment. My teeth very much needed to be straightened. At the beginning of treatment, 1 felt it would take a long time.
Dentd esihdcs I. 3. 3. 4. 5.
Before treatment began, I thought a lot about my teeth. My teeth looked attractive before treatment started. * An attractive smile is important. Teeth are most important to over-all attractiveness. When looking at a person’s face. I usually notice the teeth first.
Generul attitude I
It was not my idea to have orthodontic
2. 3. 4. 5.
I am glad I have started my orthodontic treatmen. I like my teeth more now than before treatment. I would recommend orthodontics for some of my friends. My orthodontist is very nice.
treatment. -I
Heudgrur attirudr 1. 2. 3. 4. *Lower
numerical
I dislike my orthodontic appliance or braces. * Headgear was difficult for me to wear. * It bothers me to wear my headgear in public. * II bothers me to wear headgear at home. *
ratings were assigned to true responses.
evaluated each patient’s malocclusion from plaster casts. Malocclusion was rated on a five-point scale according to difficulty in treating the patient. According to productmoment correlations, ratings of the first judge agreed moderately with those of the second judge (r = 0.52, p < 0.02) and strongly with those of the third judge (r = 0.71, p < 0.0005). However, in accord with the common observation that clinical opinions often vary, the second and third judges disagreed in their ratings (r = 0.29). The average of the three judgments was considered to be optimal for scoring each patient’s malocclusion (clinical difficulty). Dental attitudes. Patients rated themselves on a five-point scale for twenty-nine items. On the face validity of grouping eighteen items into four subsets (Table II), patients evaluated their own malocclusion (perceived severity), their sensitivity and attention to dentofacial esthetics (den& esthetics), their general rapport with orthodontic treatment (general attitude), and their comfortableness with wearing headgear (headgear attitude). Those attitudes were scored as the mean rating of each patient’s subset of items. Locus of control. The degree of internal locus of control was determined for the patient (patient locus) and the patient’s mother (mother’s locus). Mothers took Rotter’s” twenty-nine-item inventory, but the patient took only an eleven-item subtest (Nos. 2, 5, 7, 10, 11, 13, 1.5, 20, 23, 25, and 28). Since the original test was intended for adults, the subtest was considered to be more appropriate to the understanding of younger patients. The construct reliability of the subtest was quite high since the mother’s score on the twenty-nine-item full test was highly correlated with the mother’s score based on the eleven-item subtest (r = 0.82, p < 0.00001).
Volume 75 Number
Patient cooperation in wearing headgear
5
Table ill. Factor loadings and communalities
521
(hz)* in 0.01 units Factors
First period: Objective cooperation Subjective cooperation Second period: Objective cooperation Subjective cooperation Third period: Objective cooperation Subjective cooperation School cooperation Clinic cooperation Reporting directions Reporting headgear wear Years of age Headgear attitude Hours advised Treatment difficulty Perceived severity General attitude Mother’s locus of control Patient’s locus of control Dental esthetics Sex (male f, female -) Eigenvalue Percent of variance
I (Co-
II (Pa-
operation)
Gentreports)
111 (Attitudes)
IV (Locus)
h’
90 89
03 -24
05 -06
-04 -04
82 86
88 91
I8 -13
I8 03
85 90 65 61 -21 28 01 24 04 23 38 49 26 22 68 -50 7.06 54.5
27 -02 -29 -06 96 76 -43 -03 20 -29 06 01 04 -07 26 04 2.35 18.2
-11 -26 I6 02 -07 17 25 67 -65 -46 -58 45 46 19 02 -II 2.04 15.8
II 08 02 00 -09 28 -07 I2 I6 06 -25 I3 -05 -27 -37 92 -42 38 1.50 I I.6
86 86 81 88 54 45 100 70 28 51 53 37 49 52 42 95 70 40
*Communalities indicate what proportion of the variance in a variable is accounted for by a composite of all the factors.
Results Principal component factor analysis with varimax rotation revealed four meaningful factors (Table III). The description of the factors is indicated by their loadings on individual variables. The principal factor was cooperation in headgear wear. Cooperative patients received higher teacher evaluations of school cooperation and higher resident evaluations of clinic cooperation, were more sensitive to dentofacial esthetics, were female, had a better general attitude toward orthodontic treatment, and tended to perceive their malocclusion as severe. As a second factor, patients were consistent in reporting the hours they were directed to wear headgear and the hours they thought they did wear headgear. Younger patients reported more hours. The clinical ratings of malocclusion, the advice of the resident, and attitudes of patients were interrelated in a third factor. Positive associations among ratings of treatment difficulty, advice to wear headgear more hours, and patient self-perceptions of severity of malocclusion were associated negatively with comfortableness with wearing
headgear, general attitudes about orthodontic treatment, and the mother’s internal locus ot control. As a final factor, there was a sex difference in locus of control. Locus of control was more internal for male patients, but more external for female patients and the mothers of patients. A sensitivity to dentofacial esthetics was lower in patients with an internal locus of control (that is, males). Discussion The results did not support the view that younger patients are more cooperative. ‘. 2’. z In accord with the findings of Crawford” and McDonald,‘” age had no bearing on headgear wear for adolescents spanning the ages of 11 to 17 years. Nor was cooperation in wearing headgear related to the resident’s recommendations for hours of headgear wear. Patients’ self-reports of headgear wear were consistent with their reporting directions, but those subjective reports were not related to the objective facts of headgear wear. Sex differences were among the clearest findings to emerge from the factor analysis. Girls, more sensitive to dentofacial attractiveness, were better cooperators than boys. This finding supports esthetics as a major motivation for girls to wear their headgear.“, 27 While boys were less concerned about dental esthetics, they had a more internal locus of control. However, locus of control was not related clearly to cooperation in headgear wear. Patients who wore their headgear longer also had a better general attitude toward orthodontic treatment and better ratings of clinic and school cooperation. Since girls were better cooperators in wearing headgear, these ratings may reflect the social and educational maturity which girls may enjoy over boys.7 On the other hand, while these resident and teacher ratings did reflect accurately the patient’s cooperation in wearing headgear, they may reflect a bias in favor of girls, who are regarded as generally cooperative and conforming. r3. 2x To some extent, cooperative patients felt that their malocclusions were more severe. In contrast to other studies,20s z3* 29 perceptions of greater severity by the patient were realistically based on greater treatment difficulty, or the patient’s perception of greater severity resulted from the impact of a more difficult malocclusion combined with the resident’s advice to wear headgear more hours. However, when patients perceived their malocclusions as more severe, they showed less comfortableness in wearing headgear and had a poorer general attitude. The perception of severity apparently transferred to a greater self-consciousness about wearing headgear. There are several implications for the orthodontist’s strategies in dealing with uncooperative patients. Considering sex differences, the orthodontist should emphasize the esthetic value of orthodontics for girls. Since boys have a more internal locus of control, the orthodontist might motivate boys by focusing responsibility for treatment results on the boys’ own efforts. For boys, a sense of accomplishment is a value. In accord with the findings of Fitch and Moxley, r2 the orthodontist should creatively provide some measures of accomplishment. The emphasis for girls and boys, respectively. is how treatment has benefited the patient or how the patient has influenced favorable treatment results. Directing patients to focus on the severity of their malocclusion should increase cooperation in wearing headgear. The orthodontist might forcefully impress patients with the requirements for correcting their malocclusion. There is a caveat: The orthodontist should be alert to potentially unfavorable headgear attitudes in patients who perceive their
Volume 15 Number 5
Patient cooperation in wearing headgear
523
malocclusions as more severe or for whom, in fact, treatment is more difficult. For those patients, the orthodontist might best consider alternative treatment plans to extraoral mechanics which requires obtrusive, visible headgear wear. However, the patient’s acceptance of headgear wear is less important for better cooperation than is the patient’s greater appreciation of orthodontic treatment as reflected in general attitude. Summary Since successful orthodontic treatment depends upon patient cooperation, it would be useful to assess variables associated with cooperation so that the orthodontist might engender cooperation based on that understanding. Headgear wear was timed for twenty adolescent patients. The variables included overt measures, ratings of cooperation and malocclusion, various patient attitudes, and locus of control. Principal component factor analysis with varimax rotation revealed four meaningful factors. Of greatest salience to encouraging headgear wear were sex differences and the interrelationship of malocclusion and patient attitudes. Patients who most needed to wear their headgear had a greater potential for troublesome attitudes. Girls were more cooperative in wearing headgear, which was related to their more general attitude of cooperation. Girls were motivated by dentofacial esthetics more than boys, who were more inclined to perceive the consequencesof their actions as their personal responsibility. Orthodontists can promote headgear wear by taking sex differences into account, by sensitizing patients to their malocclusions, and by increasing their appreciation for treatment. REFERENCES 1. Allan, T. K., and Hodgson, E. W.: The use of personality measurements as a determinant of patient cooperation in an orthodontic practice, AM. J. ORTHOD.54: 433-440, 1968. 2. Armstrong, M. M.: Controlling the magnitude, direction, and duration of extraoral force, AM. J. ORTHOD. 59: 217-243, 1971. 3. Baldwin, D. C., Jr., and Barnes, M. L.: Psychosocial factors motivating orthodontic treatment (I.A.D.R. abstract), J. Dent. Res. 44: 153, 1965. 4. Baldwin, D. C., Jr., and Barnes, M. L.: Patterns of motivation in families seeking orthodontic treatment (I.A.D.R. abstract), J. Dent. Res. 45: 142, 1966. 5. Blechman, A. M., and Smiley, H.: Magnetic force in orthodontics, AM. J. ORTHOD.74: 435-443, 1978. 6. Broekman. R. W.: The cooperation of patients in orthodontic treatment, Oral Res. Abstr. 4: 432, 1969. 7. Burns, M. H.: Use of a personality rating scale in identifying cooperative and noncooperative orthodontic patients, AM. J. ORTHOD.57: 418, 1970. 8. Clark, J. R.: Oral hygiene in the orthodontic practice; motivation, responsibilities, and concepts, AM. J. ORTHOD.69: 72-82, 1976. 9. Crawford, T. P.: A multiple regression analysis of patient cooperation during orthodontic treatment, AM. J. ORTHOD.65: 436-437, 1974. 10. Dorsey, J., and Korabik, K.: Social and psychological motivations for orthodontic treatment, AM. J. ORTHOD.72: 460, 1977. 11. Drash, P. W.: Behavior modification; new tools for use in pediatric dentistry with the handicapped child, Dent. Clin. North Am. 18: 617-631, 1974. 12. Fitch, M., and Moxley, R., Jr.: Preventive dentistry with behavior modification, J. Am. Sot. Prev. Dent. 2: 45-46, 1972. 13. Gabriel, H. F.: Motivation of the headgear patient, Angle Orthod. 38: 129-135, 1968. 14. Gough, H.: The adjective check list manual, Palo Alto, Calif., 1965, Consulting Psychologists Press. 15. Hall, R. V., Axelrod, S., Tyler, L., Grief, E., Jones, F. C., and Robertson, R.: Modification of behavior problems in the home with a parent as observer and experimenter, J. Appl. Behav. Anal. 5: 53-64, 1972. 16. Herren, P., Bauman-Rufer, H., Demisch, A., and Berg, P.: The teacher’s questionary; an instrument for the evaluation of the psychological factors in orthodontic diagnosis, Rep. Eur. Orthod. Sot. 41: 247-262, 1965.
17. Jaffe. P. E.: The impact of the doctor-paircntipar~~nt relationbhlp on the pmcucc‘ 01 ~rrrhc&mtlc\. Angl< Orthod. 37: 323-32-1, 1967. IX. Jarabak. J. R.: Management of an orthodontic practlcr. St. Louis. 1965, The C. V Morh! Company. chap. 7, pp. 150-181. 19. Jenks. L.: How the dentist’s behavior can intluence the child’s behavior. J. Dent. Child. 31: 35X-366. 1964 20. KatL. R. V.: Relationships between eight orthodontic indices and an oral \elf-image satisfaction scale. .Abf J. ORTHOD. 73: 32X-334, 1978. 21. Kreit. L. H.. Burstone, C., and Delman, L.: Patient cooperation in orthodontic treatment, J. Am. Coil. Dent. 35: 327-332. 196X. 22. Lewis, H. G., and Brown, W. A. B.: The attitude of patients to the &rearing of a removable orthodontic appliance, Br. Dent. J. 134: X7-90, 1973. 23. Lewit, D. W., and Virolainen. K.: Conformity and independence in adolescents’ motivation for orthodontic treatment, Child Dev. 39: 1189-1200, 1968. 24. McDonald, F. T.: The influence of age on patient cooperation in orthodontic treatment. Dent. Abstr. IS: 52. 1973. 25. Northcutt, M. E.: Updating the timing headgear, J. Clin. Orthod. 9: 713-717. 1975. 26. Rotter, J. E.: Generalized expectancies for internal versus external control of reinforcement, Psychol. Monogr. 80: l-26, 1966. 27. Salzmann, J. A.: Psychological factors in patient attitudes. AM. J. ORTHOD. 58: 295-296. 1970. 28. Starnbach, H. K., and Kaplan. A.: Profile of an excellent orthodontic patient, Angle Orthod. 45: l41- 145. 1975. 29. Stricker, G.: Psychological issues in orthodontic practice, AM. J. ORTHOD. 58: 276-283. 1970. 30. Swedik, W. P.: A behavioral evaluation of patient cooperation in the use of extraoral elastic and coil spring traction devices, AM. J. ORTHOD. 74: 687, 1978. 31. Thornburg, H. D., and Thornburg, E.: How to motivate patients to care, Dent. Survey 51: 36-39. 1975. 32. Weiss. J.. and Eiser, H. M.: Psychological timing of orthodontic treatment. AM. J. OR.THOD. 72: 198-204, 1977. 33. White,
L. W.: Behavior
34. White,
L. W.: A behavioristic
modification
of orthodontic
patients, J. Clin. Orthod.
approach to oral hygiene,
3556 Caroline St. (63104)
4X5 Wildwwd Parkway (6301 I j
8: 501-505,
AM. J. ORTHOD. 72: 406413.
1974.
1977.
T
he cooperative orthodontic patient will wear headgear or elastics as directed, avoid or report appliance breakage, follow instructions regarding oral hygiene and diet, and conform to office procedures and schedules.‘, ‘Z lx, “+ *’ Successful orthodontic treatment requires the patient’s cooperation. Jarabak’s”’ observation is frequently reiterated: Lack of patient cooperation can destroy the best treatment planning and the most promising treatment mechanics.‘, 8, 27 There are a number of ways to deal with the problem of patient noncooperation. Some orthodontists have proposed that appliances be “tied in”2 or that treatment mechanics be developed which do not require active patient participation.5 On the other hand, the orthodontist can attempt to motivate the patient.i3s lx Sometimes, unfortunately, the orthodontist may become too engrossed in treatment mechanics to motivate patients properly . ‘* 17, I9 However, patients can be instructed in ways which provide a rationale for cooperative behaviors. ‘, 31 And undesirable patient behaviors can be modified or new habits can be learned.“, l*, i5. 3R,34 Moreover, through some understanding of the nature of patient cooperation in orthodontics, it would be possible (1) to identify patients who would likely be more or less cooperative and (2) to provide some rationale for promoting cooperation in patients. This is the purpose of the present study. Provided that there is some measurable behavioral criterion of patient cooperation, it would be possible to show how selected variables relate to cooperation and other independent factors. This would be possible even with a small sample of patients, provided that the sample contains both cooperators and noncooperators. Specifically, the present study defined cooperation as the actual hours of headgear wear relative to the directives of the orthodontist. Cooperation in wearing headgear was related to the most relevant measures suggested by the review of the literature. Review of the literature Since the decision to seek treatment often originates with parents rather than with patients, 3, ‘. lo* ” the patient may not be disposed to cooperate. The patient’s primary motive for seeking treatment may be an appreciation of “straight teeth.“27 Accordingly, Lewit and Virolainen23 determined that the best predictor of desire for orthodontic treatment in 129 children was their self-perceived orthodontic condition. In a study by Lewis and Brown,22 74 of 100 children stated that they continued to wear orthodontic appliances because they wanted to “look better” or to “have straight teeth.” However, patient From the Department of Orthodontics, Saint Louis University ooO2-9416/79/050517+08$00.80/0
0
1979 The C.V. Mosby Co.
517
57 8
Clemmer and HU.WS
self-perceptions or oral self-images have very little relationship to measurable malocclusion.*‘, *‘, *’ Unless malocclusion is severe, objective malocclusion is related neither to the desire to seek treatment4* ~3, 27 nor to ratings of patient cooperation.“A Some orthodontists have attempted to develop some readily accessible criteria for identifying cooperative patients. Stambach and Kaplan2x employed sociologic descriptions to classify their recollections of cooperation for 132 “excellent” and 126 “average” patients. Excellent patients tended to be female Christians with working-class fathers. Broekma# cites greater cooperation among girls, especially those over 14 years of age. However, many studies indicate that the best cooperation ratings are assigned to preadolescent patients. ‘* 2’. a2Even though Crawford” found some relationship between age and ratings of cooperation, it was not possible to predict those ratings in a beginning orthodontic patient. McDonald ” found no relationship between age and ratings of cooperation. For the most part, efforts to relate ratings of cooperation to the patient’s personality have been unsuccessful. In Allan and Hodgson’s’ study, none of the individual items on Gough’s’” Adjective Check List identified more highly rated cooperators. Gabriel’s’” posttreatment estimate of motivation for 67 patients was minimally predicted (8.4 percent of variance) from a set of items selected from the California Test of Personality (a measure of personal-social adjustment). However, McDonaldz4 found the California Test of Personality to be related to ratings of patient cooperation, as did Gossett (cited in Starnbach and KaplanzH). Other studies have used one of several inventories for assessing a patient’s “locus of control.” All of the inventories place a person on a continuum relative to internal-external locus of control. Persons with an internal locus of control feel more strongly that what they do is likely to affect what happens to them, while those with an external locus of control perceive themselves as hapless victims of uncontrollable circumstances and manipulations. Lewit and Virolainen 23found a greater desire for orthodontic treatment among patients with a more internal locus of control, but only for middle-class children with low scores on both test anxiety and social desirability. Also, Crawford9 found that locus of control was associated in an unspecified manner with ratings of patient cooperation. Consistently, ratings of patient cooperation seem to be related to the patient’s school cooperation. Kreit, Burstone, and Delman,2’ who administered a 287-question personality inventory to 1,386 patients rated on cooperation, found that uncooperative patients admitted more often that their parents did not think their grades in school were high enough. Also, cooperative patients asserted more often that they always did what their teachers told them to do. In fact, research by Herren, Baumann-Rufer, Demisch. and Berg’” and by Bums’ shows that teachers give higher ratings of school cooperation to orthodontic patients who receive higher ratings of orthodontic cooperation. These findings suggest that patient cooperation reflects the mature attitude of a generalized personality trait. Ratings of patient cooperation may or may not reflect actual patient behavior. Typically, the predictive ability of the various studies is minimal because ratings made at some distance from actual observations of patients and based on unrefined global criteria are subject to considerable imprecision and experimenter bias. By contrast, in parallel research from our clinic, Swetlik30 employed the specific behavioral criterion of cooperation-hours of headgear wear. While Swetlik did not find a relationship between headgear wear and a measure of locus of control, he did indicate that patients who were more
Volume 15 Number 5
Patient cooperation in wearing headgear
519
Table I. Patientdescriptionsof clinic cooperationcharacterizedby the treating residentas true, mostly true, neutral, mostly false, or false I. 2. 3. 4. 5. 6. 7. 8. 9. IO.
Your patient is always on time. Your patient is an excellent cooperator. Your patient is interested and attentive to your instructions. You and your patient have excellent rapport with each other. Your patient can be trusted to do exactly what he or she is told. Your patient showed great interest in his or her orthodontic treatment. Your patient could be classified as an ideal patient. Your patient would try exceptionally hard to please you. Your patient does not have to be constantly reminded to do his or her part. Your patient complained a lot. *
*Higher numerical ratings were assigned to false responses.
concerned about how they were regarded by others would initially resist headgear wear but were more likely to wear headgear 9 weeks later. The present study, as Jaffe’? and Stricker” have suggested, addresses the need for sound behavioral research to tackle orthodontic problems such as patient cooperation. Method and materials Subjects. Twenty Caucasian clinic patients were in their first year of edgewise treatment by residents of the Saint Louis University Department of Orthodontics. There were nine girls and eleven boys. The mean age of both girls and boys was 13.8 years, but the age range was more variable for girls ( 11 to 17 years) than for boys (11 to 15 years). Respective standard deviations were 1.92 and 1.25 years. Patients currently wearing cervical headgear were selected if their treatment plan called for continued headgear wear for 12 to 14 hours per day for at least three 2- to 3-week periods. Including cooperators and noncooperators, patients over-all averaged 55.8 percent of their recommended hours of headgear wear. Actual headgear wear averaged 7.43 hours per day, which was nearly 2 hours less than Swetlik’s30 observation of 9.28 hours of daily headgear wear. Overt measures. Included as variables were the sex and age of the patient. The hours of suggested headgear wear (hours advised) were recorded. After the final observation period, patients stated in hours what they thought their resident’s directives had been (reporting directions) and how many hours per day they thought they had worn their headgear (reporting headgear wear). Cooperation measures. For each 2-to 3-week period, headgear wear in hours was measured covertly by an Aledyne timerz5 incorporated into the headgear’s cervical-pull neck strap. Through pretesting, the accuracy of all the timers was determined to fall within 3 percent above or below real time. The percentage of actual headgear wear was determined relative to both the hours-per-day directives of the treating resident (objective cooperation) and the patient’s statement of those directives (subjective cooperation). The treating resident evaluated the patient’s cooperation (clinic cooperation) as the mean of ten questions rated on a five-point scale (Table I). A schoolteacher considered by the patient to be impartial also rated the patient’s cooperation in school (school cooperation) as the mean of fifteen items rated on a five-point scale.16 Malocclusion. Three clinical professors of orthodontics at Saint Louis University
Table partly
II. Patient true.
mostly
self-descriptions true,
I. 2. 3. 4.
rat&
or completely
as complrteiy
false.
mostly
false.
partly
i’alsc and
true
In general,.mv teeth are better than other people’s teeth. * My malocclusion was very bad before orthodontic treatment. My teeth very much needed to be straightened. At the beginning of treatment, 1 felt it would take a long time.
Dentd esihdcs I. 3. 3. 4. 5.
Before treatment began, I thought a lot about my teeth. My teeth looked attractive before treatment started. * An attractive smile is important. Teeth are most important to over-all attractiveness. When looking at a person’s face. I usually notice the teeth first.
Generul attitude I
It was not my idea to have orthodontic
2. 3. 4. 5.
I am glad I have started my orthodontic treatmen. I like my teeth more now than before treatment. I would recommend orthodontics for some of my friends. My orthodontist is very nice.
treatment. -I
Heudgrur attirudr 1. 2. 3. 4. *Lower
numerical
I dislike my orthodontic appliance or braces. * Headgear was difficult for me to wear. * It bothers me to wear my headgear in public. * II bothers me to wear headgear at home. *
ratings were assigned to true responses.
evaluated each patient’s malocclusion from plaster casts. Malocclusion was rated on a five-point scale according to difficulty in treating the patient. According to productmoment correlations, ratings of the first judge agreed moderately with those of the second judge (r = 0.52, p < 0.02) and strongly with those of the third judge (r = 0.71, p < 0.0005). However, in accord with the common observation that clinical opinions often vary, the second and third judges disagreed in their ratings (r = 0.29). The average of the three judgments was considered to be optimal for scoring each patient’s malocclusion (clinical difficulty). Dental attitudes. Patients rated themselves on a five-point scale for twenty-nine items. On the face validity of grouping eighteen items into four subsets (Table II), patients evaluated their own malocclusion (perceived severity), their sensitivity and attention to dentofacial esthetics (den& esthetics), their general rapport with orthodontic treatment (general attitude), and their comfortableness with wearing headgear (headgear attitude). Those attitudes were scored as the mean rating of each patient’s subset of items. Locus of control. The degree of internal locus of control was determined for the patient (patient locus) and the patient’s mother (mother’s locus). Mothers took Rotter’s” twenty-nine-item inventory, but the patient took only an eleven-item subtest (Nos. 2, 5, 7, 10, 11, 13, 1.5, 20, 23, 25, and 28). Since the original test was intended for adults, the subtest was considered to be more appropriate to the understanding of younger patients. The construct reliability of the subtest was quite high since the mother’s score on the twenty-nine-item full test was highly correlated with the mother’s score based on the eleven-item subtest (r = 0.82, p < 0.00001).
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Patient cooperation in wearing headgear
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Table ill. Factor loadings and communalities
521
(hz)* in 0.01 units Factors
First period: Objective cooperation Subjective cooperation Second period: Objective cooperation Subjective cooperation Third period: Objective cooperation Subjective cooperation School cooperation Clinic cooperation Reporting directions Reporting headgear wear Years of age Headgear attitude Hours advised Treatment difficulty Perceived severity General attitude Mother’s locus of control Patient’s locus of control Dental esthetics Sex (male f, female -) Eigenvalue Percent of variance
I (Co-
II (Pa-
operation)
Gentreports)
111 (Attitudes)
IV (Locus)
h’
90 89
03 -24
05 -06
-04 -04
82 86
88 91
I8 -13
I8 03
85 90 65 61 -21 28 01 24 04 23 38 49 26 22 68 -50 7.06 54.5
27 -02 -29 -06 96 76 -43 -03 20 -29 06 01 04 -07 26 04 2.35 18.2
-11 -26 I6 02 -07 17 25 67 -65 -46 -58 45 46 19 02 -II 2.04 15.8
II 08 02 00 -09 28 -07 I2 I6 06 -25 I3 -05 -27 -37 92 -42 38 1.50 I I.6
86 86 81 88 54 45 100 70 28 51 53 37 49 52 42 95 70 40
*Communalities indicate what proportion of the variance in a variable is accounted for by a composite of all the factors.
Results Principal component factor analysis with varimax rotation revealed four meaningful factors (Table III). The description of the factors is indicated by their loadings on individual variables. The principal factor was cooperation in headgear wear. Cooperative patients received higher teacher evaluations of school cooperation and higher resident evaluations of clinic cooperation, were more sensitive to dentofacial esthetics, were female, had a better general attitude toward orthodontic treatment, and tended to perceive their malocclusion as severe. As a second factor, patients were consistent in reporting the hours they were directed to wear headgear and the hours they thought they did wear headgear. Younger patients reported more hours. The clinical ratings of malocclusion, the advice of the resident, and attitudes of patients were interrelated in a third factor. Positive associations among ratings of treatment difficulty, advice to wear headgear more hours, and patient self-perceptions of severity of malocclusion were associated negatively with comfortableness with wearing
headgear, general attitudes about orthodontic treatment, and the mother’s internal locus ot control. As a final factor, there was a sex difference in locus of control. Locus of control was more internal for male patients, but more external for female patients and the mothers of patients. A sensitivity to dentofacial esthetics was lower in patients with an internal locus of control (that is, males). Discussion The results did not support the view that younger patients are more cooperative. ‘. 2’. z In accord with the findings of Crawford” and McDonald,‘” age had no bearing on headgear wear for adolescents spanning the ages of 11 to 17 years. Nor was cooperation in wearing headgear related to the resident’s recommendations for hours of headgear wear. Patients’ self-reports of headgear wear were consistent with their reporting directions, but those subjective reports were not related to the objective facts of headgear wear. Sex differences were among the clearest findings to emerge from the factor analysis. Girls, more sensitive to dentofacial attractiveness, were better cooperators than boys. This finding supports esthetics as a major motivation for girls to wear their headgear.“, 27 While boys were less concerned about dental esthetics, they had a more internal locus of control. However, locus of control was not related clearly to cooperation in headgear wear. Patients who wore their headgear longer also had a better general attitude toward orthodontic treatment and better ratings of clinic and school cooperation. Since girls were better cooperators in wearing headgear, these ratings may reflect the social and educational maturity which girls may enjoy over boys.7 On the other hand, while these resident and teacher ratings did reflect accurately the patient’s cooperation in wearing headgear, they may reflect a bias in favor of girls, who are regarded as generally cooperative and conforming. r3. 2x To some extent, cooperative patients felt that their malocclusions were more severe. In contrast to other studies,20s z3* 29 perceptions of greater severity by the patient were realistically based on greater treatment difficulty, or the patient’s perception of greater severity resulted from the impact of a more difficult malocclusion combined with the resident’s advice to wear headgear more hours. However, when patients perceived their malocclusions as more severe, they showed less comfortableness in wearing headgear and had a poorer general attitude. The perception of severity apparently transferred to a greater self-consciousness about wearing headgear. There are several implications for the orthodontist’s strategies in dealing with uncooperative patients. Considering sex differences, the orthodontist should emphasize the esthetic value of orthodontics for girls. Since boys have a more internal locus of control, the orthodontist might motivate boys by focusing responsibility for treatment results on the boys’ own efforts. For boys, a sense of accomplishment is a value. In accord with the findings of Fitch and Moxley, r2 the orthodontist should creatively provide some measures of accomplishment. The emphasis for girls and boys, respectively. is how treatment has benefited the patient or how the patient has influenced favorable treatment results. Directing patients to focus on the severity of their malocclusion should increase cooperation in wearing headgear. The orthodontist might forcefully impress patients with the requirements for correcting their malocclusion. There is a caveat: The orthodontist should be alert to potentially unfavorable headgear attitudes in patients who perceive their
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Patient cooperation in wearing headgear
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malocclusions as more severe or for whom, in fact, treatment is more difficult. For those patients, the orthodontist might best consider alternative treatment plans to extraoral mechanics which requires obtrusive, visible headgear wear. However, the patient’s acceptance of headgear wear is less important for better cooperation than is the patient’s greater appreciation of orthodontic treatment as reflected in general attitude. Summary Since successful orthodontic treatment depends upon patient cooperation, it would be useful to assess variables associated with cooperation so that the orthodontist might engender cooperation based on that understanding. Headgear wear was timed for twenty adolescent patients. The variables included overt measures, ratings of cooperation and malocclusion, various patient attitudes, and locus of control. Principal component factor analysis with varimax rotation revealed four meaningful factors. Of greatest salience to encouraging headgear wear were sex differences and the interrelationship of malocclusion and patient attitudes. Patients who most needed to wear their headgear had a greater potential for troublesome attitudes. Girls were more cooperative in wearing headgear, which was related to their more general attitude of cooperation. Girls were motivated by dentofacial esthetics more than boys, who were more inclined to perceive the consequencesof their actions as their personal responsibility. Orthodontists can promote headgear wear by taking sex differences into account, by sensitizing patients to their malocclusions, and by increasing their appreciation for treatment. REFERENCES 1. Allan, T. K., and Hodgson, E. W.: The use of personality measurements as a determinant of patient cooperation in an orthodontic practice, AM. J. ORTHOD.54: 433-440, 1968. 2. Armstrong, M. M.: Controlling the magnitude, direction, and duration of extraoral force, AM. J. ORTHOD. 59: 217-243, 1971. 3. Baldwin, D. C., Jr., and Barnes, M. L.: Psychosocial factors motivating orthodontic treatment (I.A.D.R. abstract), J. Dent. Res. 44: 153, 1965. 4. Baldwin, D. C., Jr., and Barnes, M. L.: Patterns of motivation in families seeking orthodontic treatment (I.A.D.R. abstract), J. Dent. Res. 45: 142, 1966. 5. Blechman, A. M., and Smiley, H.: Magnetic force in orthodontics, AM. J. ORTHOD.74: 435-443, 1978. 6. Broekman. R. W.: The cooperation of patients in orthodontic treatment, Oral Res. Abstr. 4: 432, 1969. 7. Burns, M. H.: Use of a personality rating scale in identifying cooperative and noncooperative orthodontic patients, AM. J. ORTHOD.57: 418, 1970. 8. Clark, J. R.: Oral hygiene in the orthodontic practice; motivation, responsibilities, and concepts, AM. J. ORTHOD.69: 72-82, 1976. 9. Crawford, T. P.: A multiple regression analysis of patient cooperation during orthodontic treatment, AM. J. ORTHOD.65: 436-437, 1974. 10. Dorsey, J., and Korabik, K.: Social and psychological motivations for orthodontic treatment, AM. J. ORTHOD.72: 460, 1977. 11. Drash, P. W.: Behavior modification; new tools for use in pediatric dentistry with the handicapped child, Dent. Clin. North Am. 18: 617-631, 1974. 12. Fitch, M., and Moxley, R., Jr.: Preventive dentistry with behavior modification, J. Am. Sot. Prev. Dent. 2: 45-46, 1972. 13. Gabriel, H. F.: Motivation of the headgear patient, Angle Orthod. 38: 129-135, 1968. 14. Gough, H.: The adjective check list manual, Palo Alto, Calif., 1965, Consulting Psychologists Press. 15. Hall, R. V., Axelrod, S., Tyler, L., Grief, E., Jones, F. C., and Robertson, R.: Modification of behavior problems in the home with a parent as observer and experimenter, J. Appl. Behav. Anal. 5: 53-64, 1972. 16. Herren, P., Bauman-Rufer, H., Demisch, A., and Berg, P.: The teacher’s questionary; an instrument for the evaluation of the psychological factors in orthodontic diagnosis, Rep. Eur. Orthod. Sot. 41: 247-262, 1965.
17. Jaffe. P. E.: The impact of the doctor-paircntipar~~nt relationbhlp on the pmcucc‘ 01 ~rrrhc&mtlc\. Angl< Orthod. 37: 323-32-1, 1967. IX. Jarabak. J. R.: Management of an orthodontic practlcr. St. Louis. 1965, The C. V Morh! Company. chap. 7, pp. 150-181. 19. Jenks. L.: How the dentist’s behavior can intluence the child’s behavior. J. Dent. Child. 31: 35X-366. 1964 20. KatL. R. V.: Relationships between eight orthodontic indices and an oral \elf-image satisfaction scale. .Abf J. ORTHOD. 73: 32X-334, 1978. 21. Kreit. L. H.. Burstone, C., and Delman, L.: Patient cooperation in orthodontic treatment, J. Am. Coil. Dent. 35: 327-332. 196X. 22. Lewis, H. G., and Brown, W. A. B.: The attitude of patients to the &rearing of a removable orthodontic appliance, Br. Dent. J. 134: X7-90, 1973. 23. Lewit, D. W., and Virolainen. K.: Conformity and independence in adolescents’ motivation for orthodontic treatment, Child Dev. 39: 1189-1200, 1968. 24. McDonald, F. T.: The influence of age on patient cooperation in orthodontic treatment. Dent. Abstr. IS: 52. 1973. 25. Northcutt, M. E.: Updating the timing headgear, J. Clin. Orthod. 9: 713-717. 1975. 26. Rotter, J. E.: Generalized expectancies for internal versus external control of reinforcement, Psychol. Monogr. 80: l-26, 1966. 27. Salzmann, J. A.: Psychological factors in patient attitudes. AM. J. ORTHOD. 58: 295-296. 1970. 28. Starnbach, H. K., and Kaplan. A.: Profile of an excellent orthodontic patient, Angle Orthod. 45: l41- 145. 1975. 29. Stricker, G.: Psychological issues in orthodontic practice, AM. J. ORTHOD. 58: 276-283. 1970. 30. Swedik, W. P.: A behavioral evaluation of patient cooperation in the use of extraoral elastic and coil spring traction devices, AM. J. ORTHOD. 74: 687, 1978. 31. Thornburg, H. D., and Thornburg, E.: How to motivate patients to care, Dent. Survey 51: 36-39. 1975. 32. Weiss. J.. and Eiser, H. M.: Psychological timing of orthodontic treatment. AM. J. OR.THOD. 72: 198-204, 1977. 33. White,
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1977.
