British Journal of Orthodontics

ISSN: 0301-228X (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/yjor19

Treatment Co-operation in Orthodontic Patients Viveca Brattström D.D.S., Mona Ingelsson D.D.S. & Erika Åberg D.D.S. To cite this article: Viveca Brattström D.D.S., Mona Ingelsson D.D.S. & Erika Åberg D.D.S. (1991) Treatment Co-operation in Orthodontic Patients, British Journal of Orthodontics, 18:1, 37-42, DOI: 10.1179/bjo.18.1.37 To link to this article: http://dx.doi.org/10.1179/bjo.18.1.37

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Date: 20 July 2016, At: 11:31

British Joumul of Orthodontics/ Vol. 18//991/17-42

Treatment Co-operation in Orthodontic Patients VrvEcA BRATTSTROM, D.D.S. MONA INGELSSON, D.D.S. ERIKA AoERG, D.D.S. Department of Orthodontics, Karolinska Institutct, School of Dentistry, Box 4064, Huddinge, Sweden

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Received for publication September 1989

Abstract. The aim of the present investigation was to determine the reasons for lack ofpatient co-operation and premature termination of orthodontic treatment. Over a period of 10 years files at the School of Dentistry, Hudding~. Sweden, showed that 80 patients (4 per cent) terminated treatment prematurely. These patients were interviewed regarding their reasons for not completing treatment. Lack of motivation was the most common reason given. Insufficient iriformation about orthodontic treatment and lack of communication between the orthodontist and patient were the basis for the reasons given. Orthodontists require more knowledge of psychology and should have some training in information communication in order to further reduce the level of discontinued treatments. Index wordf: Orthodontic Treatment, Co-operation, Motivation, Information.

Introduction

Due to lack of co-operation some orthodontic treatments have to be terminated prematurely. In a study of cases treated with Andresen appliances at University College Hospital, London, Cohen ( 1982) found that 23 per cent of the patients failed to complete treatment because of lack of cooperation. Moss ( 1981) reported a wastage of 18 per cent due to patients who did not complete treatment. He also indicated that patient co-operation is poorer in hospital and health service practice than in private practice. Sergl and Furk (1982a, h) found that 10 per cent of orthodontic patients discontinued treatment while H uppmann et al. (1986), in their investigation, found their rate to be 20 per cent. In Sweden most orthodontic treatment is provided by public health clinics. Treatment is free for patients below 20 years of age provided there is an acceptable orthodontic need for such treatment. As the treatment is easily available and free the frequency of prematurely terminated cases might be expected to be higher than in countries where the treatment is paid for by the parents. Ahlgren ( 1988), however, found that only 8 per cent of the patients at the School of Dentistry in Malmo did not complete treatment. That frequency is lower than 0301·228X/91/004000+00S02.00

any of the previously reported figures despite inclusion of patients who decided not to proceed with treatment following the initial diagnosis. There are several aspects that may influence a patient's decision to stop treatment. These include such factors as psychology, personality, and an understanding of the nature and type of treatment, as well as the ability to tolerate inconvenience and pain arising from the treatment itself. A child's relationship with its parents is of great importance for treatment compliance (Kreit et al., 1968). If the relationship is poor, the parents' wish for orthodontic treatment may be regarded as a demand and the orthodontist as a weapon in the hands of the parents (M iller and Larsson, 1979). Most patients are adolescents and base their wish for orthodontic treatment on aesthetics, rather than functional grounds (Crawford, 1974). Most orthodontic treatment is, however, promoted by the general practitioner (Graf et al., 1972a, b; Huppmann et al., 1986). Problems with authorities (Miller and Larsson, 1979), nervousness and intolerance (Allan and Hodgson, 1968), poor parental relationships (Kreit et al., 1968), and aggressiveness in combination with a tendency to exaggerate (Sergl et al., 1987) are some personality traits reported to be associated with poor cooperation during orthodontic treatment. © 1991 British Society for the Study of Orthodontics

38

V. Brattstrom et al.

BJO Vol. /8 No. I

Adolescent children of similar age are often at different levels in their cognitive development (Piaget, 1929, 1965). The information given to them should be easily understandable, although, it is difficult for most patients to appreciate fully the implications and demands of orthodontic treatment. Individual threshold values for pain seem to vary considerably and depends to a certain extent on the method of orthodontic treatment (Koller and Dorschl, 1977a, b; Sergl and Furk, 1982). Additionally, the ability to tolerate the inconvenience of the appliance (Kwam et al., 1987) is important.

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Objectives The aim of the present study was to find out the reasons for premature termination of treatment.

Subjects and Methods All patients, noted as not having completed their TABLE I

treatment, at the orthodontic department, School of Dentistry, Huddinge, Sweden, during the 10-year period 1976-1986, were included in the study. Anamnestic data was then recorded from the files. A letter was sent informing the patients of the project and, within a week, they were interviewed over the telephone, using a standardized formula. Answering the first question, ('Why did you stop your orthodontic treatment?') the patient was allowed to express his/her own opinion. The answers to the rest of the questions were either yes or no (Table l ). The appliances were divided into four groups. If more than one type of appliance was used during the treatment, the one with the highest rank was recorded, following the scale: (l) (2) (3) (4)

headgear; Andresen appliance; removable appliance; fixed appliance.

Interview formula and distribution of answers in per cent (%,)

Who initiated the treatment?

You Your parents Your general practitioner Someone else

22·7 16·0 61·3

Did you find something wrong with your dentition?

Yes

(%,) 65·0

No

34·9

Were you aware of the difficulties connected with the appliance?

Yes

42·9

No

57·1

If not. What lacked in information?

Pain Length of treatment Difficulties with the oral hygiene Difficulties in eating Facial aesthetics during treatment Anything else

20·3 28·4 9·5 12·2 !3·5 16·2

Did you like leaving school for treatment?

Yes

(%) 79·4

No

20·6

Were the visits long lasting?

Yes

34·9

No

65·1

Did the treatment cause pain?

Yes

41·3

No

58·7

Were you teased because of your appliance?

Yes

1·6

No

98·4

Were friends of yours also wearing orthodontic appliance?

Yes

60·3

No

39·7

50·8

No

49·2

Were you treated by many students/therapists?

Yes

If yes. Was that bad or good?

Good 60·3

Bad 39·7

Did you bite your nails during the treatment?

Yes

4!·3

No

58·7

Are you a nailbiter now?

Yes

34·9

No

65·1

Did you have problems at school during the time of treatment?

Yes

22·2

No

77-8

Were there difficulties/problems at home during time of treatment?

Yes

7-9

No

92·1

Do you regret dropping out of treatment? Unaware 9·5%

Yes

27·0

No

63·5

Are you satisfied with your dentition?

Yes

66·7

No

33·3

Do you want to start treatment again?

Yes

20·6

No

79·4

Treatment co-operation 39

BJO Fthrwary 1991

In the register 80 patients were found to have discontinued treatment, which accounted for 4 per cent of the total number of patients registered. It was possible to contact and interview 63 patients, 32 girls and 31 boys. The patients who could not be contacted had either unlisted telephone numbers (8), did not speak Swedish, or had moved abroad (5). Two adults were omitted from the group as the study was focused on children.

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Results

The distribution of answers as a percentage of the total nuinber of patients interviewed is shown in Table 1. The ages at the start of treatment are shown in Fig. 1 and treatment length in Fig. 2. The mean age for'starting treatment was 12·0 years and the mean time of treatment before discontinuation was 2·3 years. The patients' main reasons, for stopping treatment were classified into five groups. These reasons were correlated with the type of appliance (Table 2) and whether treatment was carried out by a student and/or teacher (Table 3).

Year

Fto. 2 Distribution or treatment length.

been treated by both students and teachers, and was associated with all types of appliances. Difficulties with the appliance

Patients complained about ulcers, pain, and problems with loose appliances. Complaints were found amongst those treated by both students and teachers, and was associated with all types of appliances.

Lack of motivation

This was the largest group who did not complete treatment. They were discontented with orthodontics and had other preferences in life, such as sports, ballet, or riding. Some patients who stopped keeping their appointments stated that they 'even preferred going to school'. This group of patients had

Found treatment adequate

These patients had been offered extensions to their orthodontic treatment, but found their aesthetics acceptable and, consequently, ceased treatment. Most of these patients had been treated by students .using removable appliances.

~

e

:s

z

Age

Fto. I Distribution or age at start or treatment.

40 V. Brattstrom et al.

BJO Vu/. 18 No. 1

TABLE 2

Main reasons for treatment termination correlated 10 type

11( appliance

Removable Fixed Andresen app. app.

Headgear Lack of motivation

2

7

5

15

Difficulties with the appliance

I

4

3

9

2

2

Found treatment adequate Unaware that treatment had been terminated prematurely

4

Problem with the dentist

4

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Total 5 'Yc, 8

11 18

14 22

33 52

TABLE 3 Main reasons for treatment termination to treatment in the students' ( SC) and(or teachers' clinic ( TC J

se Lack of motivation

SC+TC TC

25

Difficulties with the appliance

9

Found treatment adequate

5

Unaware that treatment had been terminated prematurely

4

Problem with the dentist

I

I

Total 44 '% 70

5

Unaware that treatment had been terminated prematurely

These patients had mainly received their treatment in the students' clinic using fixed appliance. Problem with the orthodontist

This group complained about their operator being late, dropping things in their throat, having nails that were too long or being unpleasant. Four of the five patients in this group had discontinued fixed appliance treatment in the teacher's clinic.

Discussion Patients attending the orthodontic department, School of Dentistry in Huddinge, Sweden, generally live in a newly built suburban area where the percentage of immigrants is high. This could explain the number of unlisted telephone numbers and the emigrations. The mean time before treatment ceased was high (2·3 years). This, however, only records the time

2

I

8

Total

'X,

3

29

46

6

17

26

6

10

6

10

3

5

8

14 22

63

I

100

between registration and dismissal. Some of the treatments were interceptive, involving considerable observation periods without appliances, waiting for the right time to start treatment. The patients were also given many opportunities to return to treatment before they were finally dismissed. The patients who had terminated treatment prematurely from the student's and teachers' clinics, respectively, were in proportion with the total number of patients treated at the two clinics. In this study lack of motivation was the most common reason for discontinuation of treatment. The finding is in accordance with Kraft ( 1982) who has shown that lack of motivation is the most common reason for terminating treatment. The patients who complained about difficulties in wearing their appliances should have been better warned about the possible discomforts of treatment. Although 40 per cent of the individuals found treatment to be painful, only 26 per cent claimed pain was the reason for terminating the treatment. The group who found treatment adequate was well informed, in contrast to the group that was unaware that treatment had been terminated

Treatment co-operation 41

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BJO February /99/

prematurely. The latter, even those involved with fixed appliances, had generally not realized that the appliance had been removed due to a lack of cooperation. It is unfortunate when a patient is in conflict with their dentist. The problems of wearing fixed appliances are transferred to a dislike of the operator. This might be solved by seeking another orthodontist. Graf et al. (J972a, b), and Huppmann et al. ( 1986), have shown that a desire for orthodontic treatment is mainly initiated by the general practitioner. In the present study, 61 per cent were advised to undertake orthodontic treatment by their general practitioner. Although 65 per cent claimed that they had found something wrong with their dentition, only 22 per cent had asked for treatment themselves. The majority of those contacted had been unaware of the difficulties connected with the wearing of orthodontic appliances. They felt that they had not been sufficiently informed prior to the start of treatment. During treatment in the students' clinic patients were usually looked after by a new student each year. The teachers, who are postgraduate students, might also change since they seldom spend more than 3 years at the School of Dentistry. In this study the patients did not regard change of operator as a problem or a reason for discontinuation. The number of orthodontists involved during a course of treatment, however, could explain the generally unsatisfactory level of information provided. Most patients (80 per cent) enjoyed the excuse of leaving school for a couple of hours of treatment and did not find the visits too long. Only 1·6 per cent of respondants were teased because of their appliances compared to 8·1 per cent reported by Graf et al. (J972a, b). This seems to suggest that orthodontic treatment has become more socially acceptable. Only 22 per cent of those who responded had problems at school during the time of treatment. This is surprising, since school is regarded as placing heavy demands on the children particularly during this period. Two years after treatment termination, 27 per cent regretted that they had terminated treatment prematurely and 33 per cent were not satisfied with their dentition. Only 21 per cent, however, were willing to renew orthodontic treatment.

Conclusions Orthodontists require more knowledge about child psychology and need training in communication

skills in order to help reduce the level of prematurely terminated treatments. I. The information provided to patients should be tailored more individually to the patient's age and their level of appreciation. 2. An initial demonstration of the various appliances to be used may be of value. This study has been supported by the Swedish Dental Society.

References Ahlgren, J. (1988) TioArig utviirdering av ortodontiska behandlingsresultat, Tandliikartidningen, 5. Allan, T. K. and Hodgson, E. W. (1968) The use of personality measurements as a determinant of patient cooperation in an orthodontic practice, American Journal of Orthodontics, 54, 433-440. Cohen, A. M. (1981) A study of class 11 division I malocclusions treated by the Andresen appliance, British Journal of Orthodontics, 8, 159-163. Crawford, T. P. (1974) A multiple regression analysis of patient cooperation during orthodontic treatment. American Journal of Orthodontics, 65, 436--437. Graf, H., Ehmer, U., Langbein, U. and Reinhardt, W. (1972) Keferorthopiidische Behandlungen aus der Sicht der Patienten (Beantwortung eines Fragebogens durch Patienten mit abgeschlossener Behandlung) I, Frage I -12, Deutsche Stomato/ogie, 22, 545--551. Graf, H., Ehmer, U., Langbein, U. and Reinhardt, W. (1972) Kieferorthopiidische Behandlungen a us der Sicht der Patienten (Beantwortung eines Fragebogens durch Patienten mit abgeschlossener Behandlung) 2, Frage 13-24, Deutsche Stomato/ogie, 22, 622· 629. Huppman, G., Koch, R. and Witt, E. (1986) Zur Einstellung Jugendlicher gegenuber ihrer kieferorthopiidischen Behandiung, Fortschritte der Kieferorthopiidie, 41, 91-106. Koller, S. and Drosc:hl, H. (1977) Die Kieferorthopiidische Behandlung a us der Sicht der Patienten und deren Eltern, Teil 2, Zeitschrift fur Stomato/ogie, 14, 62-73. Koller, S. and Drosc:hl, H. (1977) Die Kieferorthopiidische Behandlung a us der Sicht der Patienten und deren Eltern, Teii 3, Zeitschrift fur Stomatologie, 14, 428-440. Kraft, J. (1982) Det Abbruch der Kieferorthopiidischen Behandlung durch den Patienten, Osterreichisahe Zeitschrift fur Stomatologie, 79, 223-225. Krelt, L. H., Burstone, C. and Delman, L. (1968) Patient cooperation in orthodontic treatment, Journal of the American College of Dentists, 35, 327-332. Kvam, E., Gjerdet, H. R. and Bondevlk, 0. (1987) Traumatic ulcers and pain during orthodontic treatment, Community Dentistry and Oral Epidemiology, IS, 104-107.

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V. Brattstrom et al.

Miller, E. S. and Larson, L. L. (1979) A theory of psycho-orthodontics with practical application to office techniques, The Angle Orthodontist, 49, 85-91. M011, J. P., WIIUams, D. W. and Coben, A. M. (1981) Experience in providing orthodontic treatment in England, European Journal of Orthodontics, 3, 135-139.

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Seral, H. G. and Furk, E. (1982) Untersuchungen iiber die personlichen und familiiiren Schwierigkeiten der Patienten bei kieferorthopiidischen Behandlungen. Teil 11, Fortschrille der Kieferorthopiidie, 43, 319 324. Seral, H. G., Klaaes, U., Rauh, C. and Rupp, I. (1987) Psychische Determinanten der Mitarbeit kieferorthopiidischer Patienten--i!in Beitrag zur Frage der Kooperationsprognose. Fortschrille der Kieferorthopiidie, 48, 117 -122.

Treatment co-operation in orthodontic patients.

The aim of the present investigation was to determine the reasons for lack of patient co-operation and premature termination of orthodontic treatment...
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