Influence of supplemental written information on adolescent anxiety, motivation and compliance in early orthodontic treatment

Patient-provider communication during consultations for elective dental procedures: A scoping review

INTRODUCTION

Patient-provider communication (PPC) is a critical component of patient-centered care. Original studies have examined specific factors related to PPC during consultations for elective dental procedures, but this evidence has yet to be comprehensively summarized. This scoping review aimed to understand better the extent and depth of the available literature regarding factors that influence PPC during consultations for elective dental procedures.

METHODS

The authors considered electronically available, English-language, original research published since 1990 assessing communication during consultations for elective dental procedures. Four electronic databases, Google Scholar, and reference lists of inclusions were searched until August 2023. No quality assessment was completed. Two independent researchers assessed article eligibility. Data were charted with a narrative review approach.

RESULTS

A total of 37 studies were included. The most popular discipline studied was orthodontics. Prospective cohorts and cross-sectional were the most common study designs. Information recall, patient satisfaction, and patient comprehension were the most common outcome measures. Most studies employed questionnaires, surveys, or interviews for data collection. Nineteen factors related to PPC during elective dental consultations were identified and categorized into information delivery (4), patient-related (9), and provider-related factors (6).

CONCLUSIONS

This scoping review is the first to present a list of evidence-supported factors related to PPC in elective dental consultations. Identifying these factors is an important first step to better understanding their influence on PPC and designing interventions targeting those that may be modifiable. PPC during elective dental consultations is a dynamic, ongoing process. Several recommendations emerged that may help improve PPC, including appropriate information delivery, patient engagement, providing adequate time, and educating ourselves on approaches to PPC.

Using patients' oral photographs for oral hygiene motivation promotes periodontal health: a prospective randomized controlled trial

OBJECTIVES

The aim of this prospective, randomized, controlled, single-centered, examiner-blinded clinical trial was to evaluate the effectiveness of a personalized and visual oral health education program in addition to conventional oral hygiene education.

MATERIALS AND METHODS

Fifty-six non-smoker, right-handed participants (aged 30.34 ± 11.46 years) without clinical signs of periodontitis were randomly grouped: the intervention group (n = 28) received a personalized visualized oral health education combined with conventional oral hygiene education, and the control group (n = 28) received conventional oral hygiene education only. All participants were assessed for improved periodontal parameters (PI, GI, BOP, and PPD) at baseline, first month, and third month.

RESULTS

A significant reduction (p < 0.001) was observed in PI, GI, and BOP during two follow-up sessions compared to the baseline for the two groups. No differences were found for inter-group (p > 0.05) or intra-group (p = 1) comparison of PPD. PI (p = 0.012), GI (p = 0.032), and BOP (p = 0.024) scores were significantly reduced at the third-month follow-up assessment in the intervention group compared to the control group.

CONCLUSIONS

Clinical outcomes of periodontal health were significantly enhanced by the personalized and visual oral health education program applied in this study compared to the conventional oral hygiene education program.

CLINICAL RELEVANCE

Numerous studies reported additional interventions to the oral hygiene education program. However, we did not find any published studies investigating the role of patients' intra-oral photographs in oral care. This study's results demonstrated that a visually aided education program for oral hygiene motivation may help improve oral health.

CLINICAL TRIAL REGISTRATION

Registration number is "NCT06316505" and date of registration is 18/03/2024.

Slow-Breathing Curriculum for Stress Reduction in High School Students: Lessons Learned From a Feasibility Pilot

Purpose

Nearly one in three US adolescents meet the criteria for anxiety, an issue that has worsened with the COVID-19 pandemic. We developed a video-based slow diaphragmatic breathing stress-reduction curriculum for high school students and evaluated its feasibility, tolerability, and preliminary effectiveness.

Methods

This cluster-randomized feasibility pilot compared 5-min slow diaphragmatic breathing for 5 weeks with treatment-as-usual control among four 12th-grade public high school classes. Students individually participated after school during COVID-19-related hybrid teaching, with slow diaphragmatic breathing three times/week and breath science education once/week. Feasibility was based on completion of breathing exercises, breath science education, and preliminary effectiveness assessments, and ease/tolerability was based on qualitative assessments. Preliminary effectiveness was measured with the State-Trait Anxiety Inventory (STAI) and a timed-exhale carbon dioxide tolerance test (CO₂TT) of physiological stress response. Descriptive statistics and repeated analysis of variance were performed to quantify and compare outcomes between time periods. Human subjects research approval was granted through Western IRB–Copernicus Group (WCG IRB) [ClinicalTrials.gov, Identifier: NCT05266833.]

Results

Forty-three students consented to participate. Breath practice compliance ranged from 29 to 83% across classes and weeks, and decreased on average over the 5 weeks. Compliance with the breath science videos ranged from 43 to 86%, and that with the weekly STAI-State and CO₂TT measures varied from 36 to 86%. Compliance with ease/tolerability assessments ranged from 0 to 60%. Preliminary effectiveness assessments' compliance varied across classes from 83 to 89% during baseline, and 29 to 72% at follow-up. The curriculum was rated as somewhat-to-definitely useful/beneficial, and definitely-to-very easy/tolerable. Students reported enjoying the diaphragmatic breathing, CO₂TT, and breath science education; some found the extended exhales challenging and the curriculum and assessments time-consuming. Preliminary effectiveness analyses indicated no significant changes in STAI or CO₂TT from baseline to followup or from before to after breathing exercises (p > 0.05 for all).

Conclusions

Implementation of this 5-week slow breathing curriculum was feasible and tolerable to this cohort. Compliance, tolerability, and effectiveness may be improved with in-class participation. Future research on simple and accessible slow-breathing exercises is warranted to address today's adolescent stress-management crisis.

Trial Registration

ClinicalTrials.gov, Identifier: NCT05266833

The effectiveness of interventions to increase patient involvement in decision-making in orthodontics: A systematic review

OBJECTIVES

To examine the effectiveness of interventions that aim to increase patient involvement in treatment decisions in orthodontic, orthognathic and cleft treatment, based on patient-reported outcomes and patient knowledge.

DESIGN

Systematic review.

DATA SOURCES

OVID databases (MEDLINE, EMBASE and EBM reviews), CENTRAL, WHO's International Clinical Trials Registry Platform and reference lists of included studies.

DATA SELECTION

Studies were selected by two reviewers independently and in duplicate based on pre-defined eligibility criteria: Population: People considering or undergoing orthodontic, orthognathic or cleft treatment. Intervention: Any intervention that aims to increase patient involvement in decision-making. Outcomes: Patient-reported outcomes and patient knowledge. Studies: All experimental studies published in English from January 2000 to October 2019 were eligible.

DATA EXTRACTION

Standardised data extraction of study information and assessment of risk of bias using the Cochrane Risk of Bias Tool for RCTs and ROBINS-I for non-randomised studies of interventions.

DATA SYNTHESIS

13 randomised controlled trials were included. Due to heterogeneity in the studies, a narrative synthesis was undertaken. The majority (n=11) of studies involved orthodontic patients, with one study of cleft patients and one study of orthognathic and orthodontic patients. Six included studies reported significant differences between intervention and control groups with improved patient knowledge or better patient-reported outcomes.

CONCLUSIONS

A variety of different interventions and outcome measures were used making data synthesis challenging. There is some evidence that interventions to increase patient involvement in decision-making can improve patient-reported outcomes and patient knowledge.

Traditional vs digital communication channels for improving compliance with fixed orthodontic treatment

OBJECTIVES

To compare the efficacy of traditional and digital communication strategies in improving compliance with fixed orthodontic therapy and to investigate the effect of gender, baseline oral hygiene habits, socioeconomics, and parents' education on orthodontic compliance.

MATERIALS AND METHODS

Orthodontic patients were randomly allocated to three groups. Group 1 received traditional communication including verbal and written instructions, whereas group 2 and group 3 received, in addition to traditional communication, weekly text messages or e-mails with audiovisual links, respectively. Baseline demographics (age, gender, baseline oral hygiene habits, socioeconomics, and parents' education) as well as compliance indicators (treatment duration, failed appointments, incidence and total number of appliance breakages) were recorded. For statistical analysis, Pearson chi-square, independent t-test, and one-way analysis of variance were used (P < .05).

RESULTS

Of 120 patients (aged 12 to 18 years) recruited, 108 completed the trial (G1 = 37, G2 = 35, G3 = 36). Weekly text messages failed to improve patient compliance. On the other hand, sending weekly e-mails with audiovisual links significantly (P = .014) reduced the incidence of appliance breakage as compared with the control group. Females had a significantly lower incidence of breakage (P = .041) and a fewer total number of breakages (P = .021). Patients from households with high income had significantly better compliance (P < .05). A higher level of parents' education was significantly associated with a lower incidence and total number of breakages (P < .01).

CONCLUSIONS

Communication with patients using link-rich e-mails and reminders could improve patient compliance with fixed orthodontic treatment. Female patients, high household income, and high parent education are associated with better compliance with fixed orthodontic treatment.

Influence of Patient Attitude on Bracket Failure Rate: A Prospective Study

Objective:

The aim of this study is to assess the influence of general attitude and attitude toward orthodontic treatment on bracket failure rate.

Methods and Materials:

The sample comprised 128 orthodontic patients of both genders (82 women and 46 men), divided into two groups—adolescents (12-18 years old) and adults (19-25 years old), who underwent fixed orthodontic treatment with metallic braces. Two questionnaires were handed out—one before beginning the treatment and, the second, 6 months after the start of treatment. Both the questionnaires consisted of 12 questions with 5 options each, in which the attitude was scored from 1 to 5.

Conclusion:

Patients with poor attitude scoring had higher bracket failure rate and vice versa.

Smartphone application-assisted oral hygiene of orthodontic patients: a multicentre randomized controlled trial in adolescents

OBJECTIVE

The aim of this trial was to test whether the use of a smartphone application (app) connected to a toothbrush improves the oral hygiene compliance of adolescent orthodontic patients.

DESIGN

The study was designed as a multicentre, randomized, controlled clinical trial.

SETTING

Two academic hospitals.

ETHICAL APPROVAL

The study was approved by the ethics committee.

SUBJECTS AND METHODS

This multicentre randomized controlled trial was conducted on 38 adolescents aged 12-18 years with full-fixed orthodontic appliances. Participants were randomly assigned either to a test group that used an interactive oscillating/rotating electric toothbrush connected to a brushing aid app or to a control group that used an oscillating/rotating electric toothbrush alone. At baseline, all patients received verbal and written oral hygiene instructions.

OUTCOME MEASUREMENTS

Data collection was performed at T1 (baseline), T2 (6 weeks), T3 (12 weeks) and T4 (18 weeks-end of the study). At each time point, the plaque index (PI), gingival index (GI) and white spot lesion (WSL) score were recorded. Several app-related parameters were evaluated. Patient-related outcome measures were investigated in the test group.

RESULTS

Test and control groups were similar at baseline except for WSL score. Between T1 and T4, PI and GI decreased significantly in both groups but evolutions were globally similar in both groups. Interestingly, at T3 (12 weeks), the PI was significantly lower in the app group than in the control group (P = 0.014). Data showed a marked decline in the use of the app over time in the test group.

CONCLUSIONS

This trial, conducted over 18 weeks in two academic hospitals, showed no significant effect of the use of the app in promoting oral hygiene.

TRIAL REGISTRATION

Not registered.

Improving orthodontic patients' and parents' information recall with use of audio-visual presentation and mind mapping exercises

Design Randomised controlled trial, with blinding of operators and outcome assessors.Study population English-speaking patients aged 10 or older and parents with capacity to consent were given a 45-minute audio-visual presentation and written information on orthodontic treatment in one of three formats, either leaflets from British Orthodontic Society, generic mind map or blank mind maps.Data analysis A 30-item closed-ended questionnaire was used to test knowledge of patients and parents before (T0), at 30 minutes (T1) and 6 weeks (T2) after provision of presentation and written information. Questionnaire scores at T0, T1 and T2 were analysed using box plot, histogram and Shapiro-Wilk test.Results Ninety-three patients and 89 parents were eligible for the study, of which 88 patients (94.6%) and 77 parents (86.5%) have completed questionnaires at T0, T1 and T2. There were no significant differences in scores at T0 between the three groups. After presentation and written information were given, all three participant groups scored higher at T1 and T2. The increase in score was higher in mind map groups.Conclusions Use of audio-visual presentation and written information has improved information recall of patients and parents. The study suggests that mind maps are a superior format of written information than leaflets.

Does audiovisual information affect anxiety and perceived pain levels in miniscrew application? - a within-person randomized controlled trial

BACKGROUND

Anxiety can cause difficulties during surgical procedures. The main objective of this study was to evaluate changes in patients' anxiety and perceived pain levels after receiving audiovisual and verbal information about miniscrew application.

MATERIALS AND METHODS

Eighty-eight patients (30 males and 58 females) with a mean age of 18.18 ± 5.39 years who had fixed orthodontic treatment and required miniscrew anchorage took part in this questionnaire-based randomized controlled trial. The participants were randomly allocated to two groups and either watched a video depicting miniscrew application (study group, 44 patients) or were informed verbally about the procedure (control group, 44 patients) before miniscrew placement. The audiovisual information was given via a video containing footage of local anesthesia injection, topical antiseptic application, and miniscrew insertion. The Spielberger State-Trait Anxiety Inventory (STAI) was used to measure anxiety immediately before miniscrew application. Self-drilling miniscrews (8 mm length, 1.5 mm diameter; Aarhus System Miniscrews, American Orthodontics, Washington, USA) were placed in posterior buccal interdental region. Each patient received only one miniscrew. Postoperative pain (PP) was determined using a 100-mm horizontal visual analog scale (VAS).

RESULTS

State and total anxiety scores were significantly higher in the study group than in the control group (p = 0.009 and p = 0.011 respectively). The mean PP scores (SD) for control and study groups were 12.86 (14.22) and 12.8 (16.22), respectively. The results of Mann-Whitney U test showed no significant difference (p > 0.05). Participants' PP scores did not have a significant effect on state, trait, or total anxiety scores. There was a weak but significant positive correlation between trait anxiety and state anxiety scores in both groups.

CONCLUSION

Using an audiovisual method to inform patients about miniscrew placement increased anxiety levels but did not affect pain perception.

Effects of motivational methods on oral hygiene of orthodontic patients: A systematic review and meta-analysis

OBJECTIVE

The aim of our study was to qualitatively and quantitatively synthesize the evidence regarding ways to improve motivation of oral hygiene among orthodontic patients with fixed appliances and identify the effects of motivational methods via comparing the oral hygiene condition before and after the motivations.

METHODS

An electronic search was conducted in PubMed, Ovid, Embase, and the Crochrane Library for relevant random controlled trials (RCT) and clinical controlled trial (CCT) published before May 1, 2017 with manual search in addition. Search and selection of studies, quality assessment, data extraction and synthesis was completed by 2 reviewers independently. Plaque index (PI) and gingival index (GI) at 1, 3, 6-month were pooled with Review Manager 5.3. Bias of included studies was evaluated.

RESULTS

In total, 12 studies fulfilled the inclusion criteria of this systematic review, of which, 5 were included in the meta-analysis. Motivational methods had statistically significant advantage regarding PI in the experimental group over control group at 1, 3, 6-month, while GI was significantly better controlled in the study group at 3, 6-month. The quality of included studies was moderate.

CONCLUSION

It is worthy for orthodontists to put in additional efforts to motivate patients to maintain good oral hygiene throughout the entire treatment process.

The influence of text messages on the cooperation of Class II patients regarding the use of intermaxillary elastics

OBJECTIVES

To evaluate the influence of text messages on cooperation of Class II patients with the use of intermaxillary elastics.

MATERIALS AND METHODS

The sample consisted of 42 orthodontic patients (20 males and 22 females) aged between 14 and 34 years. They were randomly divided into one of the following two groups: a control group with 21 patients who did not receive messages and an experimental group with 21 patients who received motivational and reminder text messages. Messages were sent twice a week for a period of 3 months. The patients were instructed to wear the elastics all day, removing them only during meals and replacing them daily. All patients were instructed regarding the importance of cooperation. Measurements were performed with a digital caliper on plaster models at the beginning of elastics wear (T1) and 3 months later (T2). For intragroup and intergroup comparisons between T1 and T2, paired and unpaired t-tests, respectively, were used with a significance level of 5%.

RESULTS

Statistically significant differences were observed in the intra- and intergroup comparisons between T1 and T2. Both groups showed a decrease in the sagittal distance between upper and lower arches from T1 to T2, demonstrating the effective use of elastics. However, the experimental group showed a Class II correction that was 3.7 times greater than the control group ( P = .001).

CONCLUSIONS

Text messages had a positive influence on the cooperation of patients regarding the use of intermaxillary elastics in the orthodontic treatment of Class II malocclusion.

The association between patient's compliance and age with the bonding failure of orthodontic brackets: a cross-sectional study

Background

An efficient orthodontic treatment must aim the best occlusal result in the shortest possible time. One of the factors that can interfere in this goal is the bracket debonding during the treatment. This study aimed at assessing the different factors related to brackets failure, highlighting age and patient cooperation with treatment.

Methods

The sample comprised 199 orthodontic patients of both genders (103 women and 96 men); divided into two groups—adolescents (12 to 18 years old, 118 patients) and adults (19 to 59 years old, 81 patients). A questionnaire was applied regarding the motivation of patients to seek treatment and whether they had received information on appliance care; patients also filled out their level of cooperation with treatment in a visual analog scale (VAS). Additionally, other variables were assessed, such as the teeth with bracket debonding, the presence of deep overbite, and the use of bite plate. The Mann-Whitney test was used, and a 5% significance level was applied for analyses.

Results

It was observed that 20.1% of patients presented at least one tooth with bracket failure, and the lower arch was the most prevalent site (47.5%). Adolescents presented more debonding (25.4%) than adults (12.3%). Individuals with better VAS scores on cooperation sought treatment on their own (p = 0.042), were adults (p ≤ 0.001), and showed lower rate of failure of brackets (p ≤ 0.001). The factors related to malocclusion and treatment performed had no statistical significance.

Conclusion

Greater cooperation was expected from adult individuals who sought treatment on their own and presented low rate of bracket failure.

Failure patterns of different bracket systems and their influence on treatment duration: A retrospective cohort study

OBJECTIVES

To compare the failure pattern of four different bracket types and to assess its effect on treatment duration.

MATERIALS AND METHODS

A total of 78 white patients (28 male, 50 female) with a mean age of 12.6 years were included in this retrospective cohort study and treated for a mean period of 30.6 months. The patients were treated in a private practice with stainless steel conventionally ligated brackets, ceramic conventionally ligated brackets, stainless steel self-ligating brackets, or nickel-free self-ligating brackets. The loss of at least one bracket during the course of treatment was analyzed with Cox proportional hazards survival analyses and generalized linear regression.

RESULTS

The overall bracket failure rate at the tooth level was 14.1% (217 brackets), with significant differences according to tooth type (between 8.0%-23.4%) and bracket type (between 11.2%-20.0%). After taking confounders into account, patients treated with ceramic brackets lost more brackets (hazard ratio = 1.62; 95% confidence interval = 1.14-2.29; P = .007) than patients with stainless steel brackets. On average, treatment time increased by 0.6 months (95% confidence interval = 0.21-1.05; P = .004) for each additional failed bracket.

CONCLUSIONS

Bracket failure was more often observed with ceramic brackets and was associated with increased treatment duration.

Adolescent perceptions of orthodontic treatment risks and risk information: A qualitative study

INTRODUCTION

For effective risk communication, clinicians must understand patients' values and beliefs in relation to the risks of treatment. This qualitative study aimed to explore adolescent perceptions of orthodontic treatment risks and risk information.

METHODS

Five focus groups were carried out with 32 school/college pupils aged 12-18 in Wales, UK. Participants were purposively selected and had all experienced orthodontic treatment. A thematic approach was used for analysis and data collection was completed at the point of data saturation.

RESULTS

Four themes emerged from the data; (a) day-to-day risks of orthodontic treatment, (b) important orthodontic risk information, (c) engaging with orthodontic risk information and (d) managing the risks of orthodontic treatment. Day-to-day risks of orthodontic treatment that were affecting participants "here and now" were of most concern. Information about preventing the risks of treatment was deemed to be important. Participants did not actively seek risk information but engaged passively with information from convenient sources. Perceptions of risk susceptibility influenced participants' management of the risks of orthodontic treatment.

CONCLUSIONS

This study demonstrates that adolescent patients can understand information about the nature and severity of orthodontic treatment risks. However, adolescent patients can have false perceptions if the risks are unfamiliar, perceived only to have a future impact or if seen as easy to control. Adolescent patients must be provided with timely and easily accessible risk information and with practical solutions to prevent the risks of treatment.

CLINICAL SIGNIFICANCE

The views and experiences gathered in this study can assist clinicians to better understand their young patients' beliefs about treatment risks, facilitate effective risk communication and contribute to improved patient-centred care.

Individualized intervention to reduce anxiety in adult orthodontic patients based on Q methodology

INTRODUCTION

In this study, we used Q methodology to assess the concerns of adults seeking orthodontic treatment and to determine individualized interventions to reduce their anxiety.

METHODS

Statements of concern were derived by in-depth interviews with 70 adult patients. Q sorting methodology was then used to identify the main factors associated with anxiety in a cohort of 40 adults who had not been involved in the first part of the study. The final stage involved a randomized study in which 160 new adult patients were recruited and randomized into intervention and control groups. Participants in the intervention group sorted the statements, after which individualized interventions were implemented. Participants in the control group received routine treatment. The State-Trait Anxiety Inventory was used to measure changes in participants' anxiety levels before and during treatment.

RESULTS

In total, 41 statements were identified, and participants were classified according to 5 factors. Factor 1 participants were concerned about the lack of treatment information; factor 2 represented concerns about cost and other people's opinions; factor 3 represented concerns about impact on work related to wearing braces; factor 4 encompassed concerns about treatment effects, pain, and dental fears; and factor 5 reflected concerns about side effects and finding a partner. The mean state anxiety inventory scores for both the intervention and control groups were highest 24 hours after bonding (intervention group, 44.63 ± 4.49; control group, 49.43 ± 5.42). The intragroup state anxiety inventory scores differed significantly across the 6 time points (P <0.01), with the state anxiety inventory scores of the intervention group significantly lower than those of the control group (P <0.01) at all time points except baseline. No significant intergroup or intragroup differences were found in relation to trait anxiety.

CONCLUSIONS

Adult orthodontic patients expressed diverse concerns. Individualized interventions based on Q methodology may reduce anxiety in this patient population.

Nonpharmacologic Intervention on the Prevention of Pain and Anxiety During Pediatric Dental Care: A Systematic Review

BACKGROUND

Nonpharmacologic interventions may be used to reduce fear and anxiety during dental treatment.

OBJECTIVES

To systematically review trials on the effect of nonpharmacologic interventions in behavior, anxiety, and pain perception in children undergoing dental treatment.

DATA SOURCES

Medline, Scopus, Web of Science and CINAHL, Google Scholar, and studies' reference lists.

PARTICIPANTS AND INTERVENTIONS

Studies performed with children and adolescents that evaluated the effect of interventions on children's behavior, anxiety, and pain perception during dental treatment were included.

STUDY APPRAISAL METHODS

Independent quality assessment of the studies was carried out following the classification categories present on the Cochrane Handbook for Development of Systematic Reviews of Intervention.

RESULTS

Twenty-two articles, reporting 21 studies, were selected. Most studies tested distraction techniques. Eight studies presented bias and results were not considered. The remaining 13 studies had control groups with inactive controls, and 4 also included a variation of the intervention. Of the 4 studies assessing behavior, 3 found difference between intervention and control. Anxiety was evaluated by 10 studies: 4 found differences between intervention and control and 2 found differences between interventions. Five studies investigated pain perception: 3 found difference comparing active versus inactive interventions. In 1 of the 3, variations in the intervention decreased pain perception.

CONCLUSIONS

More research is needed to know whether the techniques are effective for improving behavior and reducing children's pain and distress during dental treatment. However, the majority of the techniques improved child's behavior, anxiety, and pain perception.

A Randomized Controlled Trial to Compare 3 Methods Designed to Enhance Adherence among Orthodontic Patients

The purpose of this study was to compare 3 methods designed to enhance adherence to oral hygiene instructions in orthodontic patients: mind map, if-then plan, and leaflet. The study was a 3-arm parallel trial involving 90 orthodontic patients. The 3 groups were mind mapping, if-then planning, and patient information tools (leaflet). Group allocation was randomized in a 1:1:1 ratio. Allocation was concealed using sealed envelopes. The participant and their parents as well as the researcher undertaking the intervention and assessing the outcomes were not blinded. The statistician undertaking the analysis was blinded. Primary outcomes were plaque levels and bleeding point index. Secondary outcomes were patients' knowledge of behaviors deemed important during orthodontic treatment and self-reported behavior. Participants were assessed at 4 time points: at the fitting of the fixed appliance (T1), at initial follow-up 6 wk later (T2, at which time they were randomly allocated to the 3 groups of intervention), 6 wk after the intervention (T3), and 18 wk postintervention (T4). Mean levels of buccal and lingual plaque, as well as the proportion of sites with bleeding sites, showed no significant differences over time (buccal plaque, F_time = 3.74, P = 0.06; lingual plaque, F_time = 2.78, P = 0.06; bleeding on probing, F_time = 0.68, P = 0.51) or between interventions over time (buccal plaque, F_int × F_time = 0.38, P = 0.68; lingual plaque, F_int × F_time = 0.30, P = 0.88; bleeding on probing, F_int × F_time = 0.70, P = 0.59). There were no harmful consequences detected for any of the interventions. No single method of presenting the information proved superior to any other. This trial was registered with the Guy's & St Thomas's NHS Trust Research & Development Database. Knowledge Transfer Statement: Enhancing patient adherence to advice given by their clinician is an important component of orthodontic treatment. This study explored the use of structured techniques to enhance adherence. All 3 techniques enhanced adherence over the 18-wk study period when orthodontic treatment was being provided, but no single method proved superior to any other.

Research information for minors: Suitable formats and readability. A systematic review

As children age, their capacity to consent or dissent to research participation increases. Numerous regulations and guidelines require that children should receive information 'according to their capacity of understanding'. In order to gain more insight in the quality of patient information forms for minors, a systematic literature search was performed. Two aspects of quality will be analysed in this paper: the effect of format on understanding and the readability of text in the documents. A systematic search was executed in PubMed, Embase and PsycINFO. Seventeen papers on format were included. Interventions testing information formats indicate that improvement is possible, but outcome measurement varied per study and no apparently successful intervention was repeated. Only three readability papers were found, all indicating a readability gap between patient information forms and children's actual reading level. The results indicate an urgent need for further research on how to adequately inform minors about clinical trials.

A systematic review of randomized controlled trials of interventions to improve adherence among orthodontic patients aged 12 to 18

OBJECTIVE

To investigate the effectiveness of interventions to enhance adherence among orthodontic patients aged 12 to 18 years. Specific adherence outcomes included were recall of information given by the orthodontic team, attendance at orthodontic appointments, self-reported oral hygiene behavior, and clinical indexes of oral hygiene.

MATERIALS AND METHODS

Electronic searches of Medline via OVID (January 1, 1966 through March 1, 2012), EMBASE, and the Cochrane central register of control trials from its inception through March 2012, as well as a hand search, were undertaken to identify relevant studies.

RESULTS

Through the electronic searches, 381 article were identified. Initial screening of the abstracts and titles by all review authors identified 21 articles that met the inclusion criteria for this review. The full articles were then retrieved. Four randomized controlled trials were found, all of which used different methods of intervention: a system of rewards or awards, the Hawthorne effect, written information, and demonstration of the microbiology of plaque. All the interventions, except the use of award/reward, were associated with improvements in adherence.

CONCLUSION

The literature advocates the use of several methods to improve compliance/adherence among orthodontic patients. Although there is insufficient evidence to allow clinicians to choose a single method, the results demonstrate the value of spending time with patients to illustrate the importance of adherence. Future studies should develop multiple methods of assessing patient adherence, including self-report, behavioral observation and recording, and change in clinical indexes. Such studies should test different types of interventions for effectiveness.

Interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures

BACKGROUND

Achieving informed consent is a core clinical procedure and is required before any surgical or invasive procedure is undertaken.  However, it is a complex process which requires patients be provided with information which they can understand and retain, opportunity to consider their options, and to be able to express their opinions and ask questions.  There is evidence that at present some patients undergo procedures without informed consent being achieved.

OBJECTIVES

To assess the effects on patients, clinicians and the healthcare system of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare treatments and procedures.

SEARCH METHODS

We searched the following databases using keywords and medical subject headings: Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library, Issue 5, 2012), MEDLINE (OvidSP) (1950 to July 2011), EMBASE (OvidSP) (1980 to July 2011) and PsycINFO (OvidSP) (1806 to July 2011). We applied no language or date restrictions within the search. We also searched reference lists of included studies.

SELECTION CRITERIA

Randomised controlled trials and cluster randomised trials of interventions to promote informed consent for patients undergoing surgical and other invasive healthcare procedures. We considered an intervention to be intended to promote informed consent when information delivery about the procedure was enhanced (either by providing more information or through, for example, using new written materials), or if more opportunity to consider or deliberate on the information was provided.

DATA COLLECTION AND ANALYSIS

Two authors assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of outcomes where there were sufficient data.

MAIN RESULTS

We included 65 randomised controlled trials from 12 countries involving patients undergoing a variety of procedures in hospitals. Nine thousand and twenty one patients were randomised and entered into these studies. Interventions used various designs and formats but the main data for results were from studies using written materials, audio-visual materials and decision aids. Some interventions were delivered before admission to hospital for the procedure while others were delivered on admission.Only one study attempted to measure the primary outcome, which was informed consent as a unified concept, but this study was at high risk of bias.  More commonly, studies measured secondary outcomes which were individual components of informed consent such as knowledge, anxiety, and satisfaction with the consent process.  Important but less commonly-measured outcomes were deliberation, decisional conflict, uptake of procedures and length of consultation.Meta-analyses showed statistically-significant improvements in knowledge when measured immediately after interventions (SMD 0.53 (95% CI 0.37 to 0.69) I(2) 73%), shortly afterwards (between 24 hours and 14 days) (SMD 0.68 (95% CI 0.42 to 0.93) I(2) 85%) and at a later date (15 days or more) (SMD 0.78 (95% CI 0.50 to 1.06) I(2) 82%). Satisfaction with decision making was also increased (SMD 2.25 (95% CI 1.36 to 3.15) I(2) 99%) and decisional conflict was reduced (SMD -1.80 (95% CI -3.46 to -0.14) I(2) 99%). No statistically-significant differences were found for generalised anxiety (SMD -0.11 (95% CI -0.35 to 0.13) I(2) 82%), anxiety with the consent process (SMD 0.01 (95% CI -0.21 to 0.23) I(2) 70%) and satisfaction with the consent process (SMD 0.12 (95% CI -0.09 to 0.32) I(2) 76%). Consultation length was increased in those studies with continuous data (mean increase 1.66 minutes (95% CI 0.82 to 2.50) I(2) 0%) and in the one study with non-parametric data (control 8.0 minutes versus intervention 11.9 minutes, interquartile range (IQR) of 4 to 11.9 and 7.2 to 15.0 respectively). There were limited data for other outcomes.In general, sensitivity analyses removing studies at high risk of bias made little difference to the overall results. 

AUTHORS' CONCLUSIONS

Informed consent is an important ethical and practical part of patient care.  We have identified efforts by researchers to investigate interventions which seek to improve information delivery and consideration of information to enhance informed consent.  The interventions used consistently improve patient knowledge, an important prerequisite for informed consent.  This is encouraging and these measures could be widely employed although we are not able to say with confidence which types of interventions are preferable. Our results should be interpreted with caution due to the high levels of heterogeneity associated with many of the main analyses although we believe there is broad evidence of beneficial outcomes for patients with the pragmatic application of interventions. Only one study attempted to measure informed consent as a unified concept.

Psychosocial predictors of affect in adult patients undergoing orthodontic treatment

In this paper we propose to study the role of psychosocial variables in affect in adult patients undergoing orthodontic treatment, considering that affect is a key variable in treatment adherence. Seventy-four patients (average age 33,24 ± 10,56) with metal multibracket-fixed orthodontic treatment were included. Patients were assessed twice. The first stage, at the beginning of treatment, included assessment of dental impact (Psychosocial Impact of Dental Aesthetics Questionnaire), trait anxiety (State-Trait Anxiety Inventory), self-esteem (Rosenberg's self-esteem scale), and self-efficacy (General Self-efficacy Scale). In the second stage, 6 months later, positive and negative affect towards treatment was assessed using the Positive and Negative Affect Scale. Dental social impact differentiates between patients with high and low negative affect, while self-efficacy differentiates between patients with high and low positive affect. Trait anxiety and self-esteem differentiate between both types of affect (positive and negative). Trait anxiety and self-esteem (when trait anxiety weight is controlled) are significant predictor variables of affective balance. These results have important practical implications, because it seems essential to adopt a bio-psychosocial model incorporating assessment methods focusing on day-to-day changes in mood and well-being.

Comparing two methods of delivering neuropsychological feedback

Feedback methods have been studied in medical and psychotherapy settings, but limited research is available in neuropsychology. The purpose of this study was to examine whether supplementing oral feedback with written information would lead to greater retention of information and improved adherence to recommendations. Seventy-two veterans were enrolled in the study and randomized to receive oral feedback only or oral feedback with written information. The participants were then interviewed immediately after feedback and 1 month later by phone. Univariate analyses revealed that the written group freely recalled more recommendations at the phone interview; however, there were no differences in recall of diagnostic information or the number of recommendations attempted. Findings indicate that receiving supplemental written information improves recall of recommendations and that patients prefer to receive written information in addition to oral feedback. Recommendations to improve the retention of feedback information are discussed.

Evaluation of anxiety level changes during the first three months of orthodontic treatment

Objective

To determine the changes in dental anxiety, state anxiety, and trait anxiety levels of patients and their parents after 3 months of active orthodontic treatment.

Methods

We evaluated 120 patients and one parent of each patient. State Anxiety (STAI-S), Trait Anxiety (STAI-T), and Corah's Dental Anxiety Scale (DAS) were administered before orthodontic treatment (T1) and after 3 months of treatment (T2). Differences in scores between T1 and T2 were compared using paired-sample t-tests and the relationship between the scores of the DAS and the STAI were analyzed using a bivariate two-tailed Pearson correlation test.

Results

Dental anxiety and state anxiety levels decreased among the patients after adjustment to orthodontic treatment (p < 0.001). However, 3 months of treatment was not sufficient to decrease the anxiety levels of parents (p > 0.05). Patient trait anxiety affected patient state anxiety and dental anxiety (p < 0.01). Additionally, a significant correlation was found between patient dental anxiety and parent dental anxiety (p < 0.05).

Conclusions

Dental anxiety and state anxiety levels decrease after patients become familiar with their orthodontist and they became accustomed to orthodontic treatment. However, 3 months is not a sufficient length of time to decrease parental anxiety levels.

A new style of orthognathic clinic

The Orthognathic Team at the Eastman Dental Hospital has developed a new style of multidisciplinary clinic to supplement the traditional orthognathic consultation. The aim of the new clinic is to increase patient satisfaction and involvement in the consent and decision making process, as well as optimizing the information given to prospective patients regarding all aspects of this complex elective treatment. Results of a survey of patients attending the clinic found that 80% thought that the information given was 'just the right amount' and 96% were satisfied with the new structure. They particularly found it useful to meet a patient who had completed treatment. All of those who attended said that they understood the information given to them and would recommend the clinic to those considering orthognathic treatment. They also liked having other patients there with them on the clinic.