Patient compliance and locus of control in orthodontic treatment: a prospective study

Patient adherence in orthodontics: a scoping review

BACKGROUND

Patient adherence is a key factor in achieving orthodontic treatment success. Despite an evolution in orthodontic healthcare, no recent comprehensive reviews are available on patient adherence in orthodontics. This scoping review provides an evidence-based overview of the literature available on multiple aspects of patient adherence in orthodontics, during both active treatment as well as during the retention phase. Knowledge gaps identified in the literature are listed.

METHODS

The protocol for this scoping review was registered in the Open Science Framework ( https://doi.org/10.17605/OSF.IO/EC6QD ). Electronic databases and reference lists of relevant studies were searched up to 9 February 2023. The inclusion criteria were studies investigating any form of patient adherence in orthodontics published in English from 2006 onwards. The exclusion criteria were studies investigating adherence in the following patients: those with an intellectual or physical disability that could affect their ability to coincide with their therapist's recommendations and advice, those with oral cleft and craniofacial conditions, and those treated solely for obstructive sleep apnoea. Non-peer-reviewed studies and case reports were also excluded.

RESULTS

A total of 3284 articles were identified, 60 of which met the criteria for final inclusion.

CONCLUSIONS

There is no conclusive evidence on which factors have a significant impact on patient adherence and how patient adherence can be promoted. The degree of patient adherence is generally not compared to achieved treatment results or stability of treatment results, making it difficult to provide clear statements about the impact of the degree of adherence on desired treatment results or orthodontic stability.

Influence of Reminder on Enhancing Compliance in Patients with Fixed Orthodontic Appliance Treatment (a Randomized Controlled Clinical Trial)

Purpose

Patient compliance during orthodontic treatment has a significant effect on the aims, outcome, and duration of the treatment. The aim of this study is to evaluate the influence of reminders on enhancing orthodontic patient compliance.

Patients and Methods

Twenty-six subjects undergoing orthodontic treatment with fixed appliances were randomly assigned into two groups: control (Ct) and intervention (In) groups. The oral hygiene parameters of plaque index (PI), bleeding index (BI), and white spot lesion (WSL) with appointment adherence and bracket fracture were recorded at base line (T0), 2 months (T1), 4 months (T2), and 6 months (T3). In group participants received weekly reminders and subjects' compliances were classified into poor, fair, and excellent compliance.

Results

Statistically significant differences were found in PI level at T2 between Ct and In groups (p-value = 0.006), whereas a non-significant difference was found for BI (p-value>0. 05). There was a statistically significant increase in WSL for the Ct group across the study time points (p-value = 0.03), while no significant change in WSL was detected for the In group (p-value>0.05). The compliance levels of In and Ct groups were excellent and fair, respectively.

Conclusion

The study suggests that weekly reminders can enhance the oral hygiene status in patients with orthodontic appliances (POA) and elevate the level of compliance to excellent.

Registration number

ClinicalTrials.gov NCT05331820.

Wearable Orofacial Technology and Orthodontics

Wearable technology to augment traditional approaches are increasingly being added to the arsenals of treatment providers. Wearable technology generally refers to electronic systems, devices, or sensors that are usually worn on or are in close proximity to the human body. Wearables may be stand-alone or integrated into materials that are worn on the body. What sets medical wearables apart from other systems is their ability to collect, store, and relay information regarding an individual's current body status to other devices operating on compatible networks in naturalistic settings. The last decade has witnessed a steady increase in the use of wearables specific to the orofacial region. Applications range from supplementing diagnosis, tracking treatment progress, monitoring patient compliance, and better understanding the jaw's functional and parafunctional activities. Orofacial wearable devices may be unimodal or incorporate multiple sensing modalities. The objective data collected continuously, in real time, in naturalistic settings using these orofacial wearables provide opportunities to formulate accurate and personalized treatment strategies. In the not-too-distant future, it is anticipated that information about an individual's current oral health status may provide patient-centric personalized care to prevent, diagnose, and treat oral diseases, with wearables playing a key role. In this review, we examine the progress achieved, summarize applications of orthodontic relevance and examine the future potential of orofacial wearables.

Factors Influencing Appliance Wearing Time during Orthodontic Treatments: A Literature Review

This review aims to analyze the multiple factors affecting patients’ level of compliance (how much they wear removable devices/clear aligners) during orthodontic treatments and to investigate the available methods and devices to monitor the appliance wearing time and to improve it. A literature search was conducted on electronic databases (Pubmed, Scopus, and Google Scholar). The results of the present study suggest that compliance indicators may misestimate the intraoral wearing time. Compliance is affected by patient-related factors (age, personality traits, the importance of personal appearance, self-perception of malocclusion), appliance-related factors (visibility, pain/discomfort), and clinician-related factors (trust, clear and complete communication, motivation). The motivation of pre-pubertal patients is mostly external, while adolescents/young adults have intrinsic motivation for orthodontic treatment. Patients’ self-reports tend to overestimate the appliance wearing time. Even if there is a lack of evidence, teledentistry might improve patients’ awareness of being monitored, thus increasing the time for which orthodontic devices are worn. Compliance is a key factor for clear aligner treatments, but high-quality studies focusing on this aspect are missing. Further studies should focus on how to handle the lack of cooperation and how to increase compliance in order to maximize the treatment’s results.

Direct printed removable appliances: A new approach for the Twin-block appliance

Removable appliances are an important part of orthodontic treatment. The Twin-block is widely used for Class II correction. Traditionally, an impression, bite registration, and mounted plaster casts are required to fabricate the acrylic appliance, which usually requires a specialized laboratory. This makes the process expensive and also time-consuming. This paper aims to present an innovative approach for the virtual design and direct printing of removable orthodontic appliances, particularly the Twin-block, that can be done in-office without the need for casts or a specialized laboratory.

Short-Term and Long-Term Changes of Nasal Soft Tissue after Rapid Maxillary Expansion (RME) with Tooth-Borne and Bone-Borne Devices. A CBCT Retrospective Study

The objective of the study was to assess the changes in nasal soft tissues after RME was performed with tooth-borne (TB) and bone-borne (BB) appliances. Methods. This study included 40 subjects with a diagnosis of posterior cross-bite who received tooth-borne RME (TB, average age: 11.75 ± 1.13 years) or bone-borne RME (BB, average age: 12.68 ± 1.31 years). Cone-beam computed tomography (CBCT) was taken before treatment (T0), after a 6-month retention period (T1), and one year after retention (T2). Specific linear measurements of the skeletal components and of the soft-tissue region of the nose were performed. All data were statistically analyzed. Results. Concerning skeletal measurements, the BB group showed a greater skeletal expansion of the anterior and posterior region of the nose compared to the TB group (p < 0.05) immediately after RME. Both TB and BB RME induce a small increment (>1 mm) of the alar base and alar width, without significant differences between the two expansion methods (p > 0.05). A high correlation was found between skeletal and soft-tissue expansion in the TB group; instead, a weaker correlation was found in the BB group. Conclusion. A similar slight increment of the alar width and alar base width was found in both TB and BB groups. However, the clinical relevance of these differences, in terms of facial appearance, remains questionable.

Comparing retainers constructed on conventional stone models and on 3D printed models: a randomized crossover clinical study

OBJECTIVES

The aim of this study was to compare vacuum-formed thermoplastic retainers (VFRs) constructed on stone models (VFR-CV) and those constructed on three-dimensional (3D) printed models (VFR-3D) based on patients' perspective and post-treatment stability.

STUDY DESIGN

The research was designed as a crossover, randomized control trial.

MATERIALS AND METHODS

Subjects comprised patients receiving fixed appliances at a teaching institution and indicated for VFRs. Post-treatment stone models were scanned with a structured-light scanner. A fused deposition modelling machine was used to construct acrylonitrile-butadiene-styrene (ABS)-based replicas from the 3D scanned images. VFRs were fabricated on the original stone and printed models. Analysis comprised independent t-tests and repeated measures analysis of variance.

RANDOMIZATION

Subjects were allocated to two groups using Latin squares methods and simple randomization. A week after debond, subjects received either VFR-CV first (group A) or VFR-3D first (group B) for 3 months, then the interventions were crossed over for another 3 months.

BLINDING

In this single-blinded study, subjects were assigned a blinding code for data entry; data were analysed by a third party.

OUTCOME MEASURES

The primary outcome measured was oral health-related quality of life (OHRQoL) based on Oral Health Impact Profile-14 (OHIP-14). Secondary outcome was post-treatment stability measured using Little's Irregularity Index (LII).

RESULTS

A total of 30 subjects (15 in each group) were recruited but 3 dropped out. Analysis included 13 subjects from group A and 14 subjects from group B. Group A showed an increase in LII (P < 0.05) after wearing VFR-CV and VFR-3D, whereas group B had no significant increase in LII after wearing both VFRs. Both groups reported significant improvement in OHRQoL after the first intervention but no significant differences after the second intervention. LII changes and OHIP-14 scores at T2 and T3 between groups, and overall between the retainers were not significantly different. No harm was reported during the study.

CONCLUSION

VFRs made on ABS-based 3D printed models showed no differences in terms of patients' OHRQoL and stability compared with conventionally made retainers.

REGISTRATION

NCT02866617 (ClinicalTrials.gov).

Evaluation of bracket failure in relation to different factors in patients experiencing comprehensive orthodontic treatment: A Retrospective Cohort Study

Objective: The aim of this study was to investigate loose brackets in relation to various related factors in orthodontic patients who had completed orthodontic treatment. Material and Methods: In this retrospective study, 738 medical records of patients who had undergone comprehensive orthodontic treatment and matched specific inclusion criteria were selected. Paired t-tests and ANOVA, along with the Mann-Whitney test and Kruskal–Wallis analyses were performed to compare the means of variables between selected subgroups. Results: Loose brackets were found most frequently on premolars, followed by incisors and then canines (p<0.01). Male and young patients were found to have a higher incidence of loose brackets compared to female and adult patients (p=0.044 and p<0.01, respectively). The highest correlation coefficient value was found between treatment duration and total number of loose brackets (0.393), which was statistically significant. Conclusions: The frequency of total number of loose brackets increased with younger age group. Premolar teeth were found to be the most commonly affected teeth, followed by incisors and canines. Mandibular teeth presented more loose brackets than maxillary.

Objective assessment of compliance with intra- and extraoral removable appliances

OBJECTIVE

To conduct an objective assessment of the level of compliance in young patients prescribed various types of removable appliances and to determine the influence of device type, treatment duration, and patient age, gender, psychological maturity, and awareness of monitoring on compliance.

MATERIALS AND METHODS

A total of 30 patients were fitted with either a class 2 (Frankel or bionator) or a class 3 (face mask) removable appliance, each bearing a compliance indicator chip, and they were instructed to wear them for 13 hours per day. Compliance was monitored by means of the sensor for an average of 8 months. Of the patients, 14 were informed that their appliance was fitted with a monitoring sensor, and 16 were not. The psychological maturity of all patients was assessed on the Nowicki-Strickland Locus of Control Scale, and the effect on compliance of this score as well as the patient- and treatment-related variables considered were determined via statistical analysis Results: The mean compliance recorded by the chips was 8.6 ± 2.9 hours, far lower than the 13 hours prescribed, and younger patients showed significantly greater compliance than adolescents (P < .01). However, no significant differences in compliance were found between intra- and extraoral appliances, and neither gender, psychological scores, treatment duration, nor awareness of being monitored had any significant effect.

CONCLUSIONS

Compliance is generally very poor in young patients, regardless of their gender and psychological maturity. Although awareness of monitoring does not appear to boost compliance, such systems may be a valuable means of providing a dentist with objective information regarding their patients' compliance.

Performance of clear vacuum-formed thermoplastic retainers depending on retention protocol: a systematic review

We aimed at comparing the performance of vacuum-formed thermoplastic retainers (VFR) worn either full-time or part-time, in maintaining orthodontic treatment results in terms of tooth alignment, arch form and occlusion. We reviewed randomized and prospective controlled clinical trials comparing VFR wearing protocols and searched databases, without restrictions, for published and unpublished literature. The risk of bias was assessed using the Cochrane Risk of Bias tool and the overall level of certainty in the evidence following ADA methodology. 184 studies were initially identified and reduced to the 3 randomized controlled trials included in the systematic review by means of specific criteria. One study followed patients 1 year into retention, and the other two for 6 months. Little's Irregularity Index, intermolar and intercanine width, arch length, overjet and PAR score did not differ significantly between the patients wearing their retainers part time or full time. We observed a slight increase in the overbite in the part-time group in only one trial. With a moderate level of certainty, we found that during the observation period, full-time VFR wear is not superior to part-time, bearing in mind the potential implications for health burden, retainer longevity and cost-effectiveness, as well as patient satisfaction and compliance.

Assessment of Factors Affecting Adolescent Patients' Compliance with Hawley and Vacuum Formed Retainers

INTRODUCTION

Success of orthodontic retention with removable retainers almost entirely depends on patients' compliance.

AIM

This study was carried out to investigate the relationship between adolescent orthodontic patients' compliance and various clinical and social factors.

MATERIALS AND METHODS

The data were collected from 77 orthodontic patients aged 7-11 years old who had finished the full fixed appliance therapy. Hawley's retainers were used in 34 patients and 43 patients used Vacuum Formed Retainers (VFRs). The subjects completed a questionnaire including several identifiers allowing the respondents to be classified into subgroups. They were also asked to indicate how long they wore their retainers during the day, by writing the number of hours in the report-card for the next three months. Comparison of the results was performed by one-way ANOVA and independent sample-t tests.

RESULTS

No significant differences were found between males and females. Type of the retainer, patients' grade of study, mothers' occupation, clinicians' and parents' attitudes and filling the report cards had significant effect on mean wear hours per day. When compliance of the patients was assessed according to treatment location, Living place, parents' educational degrees and ethnicity, no significant differences could be found.

CONCLUSION

The adolescent patients' compliance was greater with VFRs than with Hawley's retainers. Parental attitude and doctor-patient relationship had a great impact on adolescent patients' compliance.

Objective assessment of patient compliance with removable orthodontic appliances: a cross-sectional cohort study

OBJECTIVE

To assess objectively patient compliance with removable orthodontic appliances and the effect of possible influential factors.

MATERIALS AND METHODS

Wearing times of 45 White patients were recorded with the aid of the TheraMon microsensor. Patient compliance was assessed relative to wear prescription and other parameters, such as age and sex.

RESULTS

There was high individual variation in most measured variables and in all groups/subgroups. During a median observation period of 186 days (range, 55-318 days) the actual wear time was 9.0 h/d (range, 0.0-16.0 h/d) and did not differ between distinct prescriptions (P = .49). Eight patients wore their appliances less than 2 h/d, and six of them did not wear their appliances at all. Overall, the median wear per day relative to prescription was 62.5% (range, 0.0-89.3%) for the 14 h/d and 112.5% (range, 0.0-200.0%) for the 8 h/d prescription wear (P = .01) groups. There was a strong negative correlation of age (median: 12.5 years) with the daily percentage of actual wear time per day relative to wear prescription (14 h/d prescription: n = 21, rho = -0.61, P = .00; 8 h/d prescription: n = 24, rho = -0.73, P = .00), while sex did not exert a significant influence on compliance (P = .58).

CONCLUSIONS

Despite the fact that patients and parents were informed about wear time recording, compliance was insufficient with regard to functional treatment (14 h/d prescription), while it was sufficient for retention purposes (8 h/d prescription). Objective measures are necessary to assess compliance with removable orthodontic appliances since patient compliance is a highly variable issue.

Higher medical morbidity burden is associated with external locus of control

OBJECTIVES

To describe the association between an increasing number of coexisting conditions and locus of control (LOC), a psychological construct reflecting the degree to which one perceives circumstances to be controlled by personal actions (internal LOC) versus outside factors (external LOC) in older adults.

DESIGN

Cross-sectional study using survey data from the North Carolina Established Population for Epidemiologic Studies of the Elderly (NC EPESE) data set.

SETTING

Community.

PARTICIPANTS

Three thousand two hundred twelve community-dwelling adults aged 68 and older.

MEASUREMENTS

Nine common medical conditions were assessed according to self-report. LOC was measured using a standard questionnaire. Analyses were adjusted for demographics, functional status (self-reported activities of daily living), cognition (Short Portable Mental Status Questionnaire), and depression score (Center for Epidemiologic Studies Depression Scale).

RESULTS

A higher number of chronic conditions was associated with external LOC (β = 0.37, P < .001). This relationship persisted after adjustment for age, race, sex, functional status, cognition, and depression (β = 0.17, P < .001). Most individual conditions were not associated with LOC, although vision impairment (P < .001) and arthritis (P = .02) were associated with more-internal LOC.

CONCLUSION

These results suggest that medically complex patients tend to exhibit a more-external LOC, meaning that they perceive little personal control over circumstances and environment. Clinicians should be aware of this tendency, because external LOC may impede an older adult's willingness to engage in the considerable task of managing multiple chronic conditions.

Development of a measure for orthodontists to evaluate patient compliance

INTRODUCTION

Interruption of treatment and poor compliance are problems in orthodontics, especially when the patient does not pay for treatment. The aim of this study was to develop a measure for orthodontists, regardless of type of practice, to assess their opinions about patient compliance.

METHODS

A questionnaire, based on an orthodontic patient cooperation scale, was modified in 2 pilot phases. The piloted version was tested among 249 respondents. A principal component analysis was performed that included factors with an eigenvalue greater than 1. Reliability was assessed by means of internal consistency with Cronbach's alphas and by test-retest (n = 40) measures, using an intraclass correlation coefficient. To assess construct validity, the responses of private and public practitioners were analyzed with chi-square and t tests.

RESULTS

The response rate was 77%. The final questionnaire showed good reliability: Cronbach's alpha coefficient was 0.878, and the intraclass correlation coefficient after the test-retest was 0.868. The participation rate was good, there were few missing values, and the study was multifaceted; thus the questionnaire also showed good validity for face, content, and construct. The differences between private and public practitioners were statistically significant. Five factors describing the different aspects of compliance were shown.

CONCLUSIONS

Observed differences between public and private orthodontists and dentists performing orthodontics indicated clearly the need to develop a specific measure for countries with a publicly funded system of oral health care. The measure showed good reliability and validity for face, content, and construct among Finnish orthodontists and dentists performing orthodontics. The predictive validity of the measure to assess actual patient compliance remains to be tested.

Color fading of the blue compliance indicator encapsulated in removable clear Invisalign Teen® aligners

OBJECTIVE

To evaluate the color fading in aqueous solutions of the blue dot wear-compliance indicators of the Invisalign Teen® System outside the oral cavity.

MATERIALS AND METHODS

The compliance indicators in the Invisalign Teen aligners were tested for color resistance in various aqueous models with no saliva involved.

RESULTS

Color fading was observed as a function of time, pH, and temperature while compliance indicators were stored in drinking water or sour soft drinks and in conjunction with the use of cleaning tablets and a dishwasher. The findings of color fading were consistent with the color changes observed when the aligners were being worn by patients. Color fading, notably as observed in connection with acidic soft drinks and cleaning techniques, introduces uncertainty into the assessment of actual patient compliance, as reflected by the fading colors of compliance indicators.

CONCLUSION

Compliance indicators are not immune to simple intentional or unintentional manipulations. Therefore, they can best show an estimate of wear time but cannot be recommended as objective wear-time indicators.