Research Article I - Sri Lanka Dental Associationcontrol.slda.lk/media/sldj/47_01_2017/Ressearch_article_1_.pdf · undergoing orthodontic treatment with removable and fixed appliances

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Research Article I

Assessment of Factors Associated with Patient’s Compliance in Orthodontic Treatment

V.S.N. Vithanaarachchi, S.P.N.P. Nagarathne, Chantha Jayawardena and L.S. Nawarathna

Sri Lanka Dental Journal 2017; 47(01) 01-12

V.S.N. Vithanaarachchi(correspondence)S.P.N.P. Nagarathne

Chantha Jayawardena

L.S. Nawarathna

(BDS, MS) Senior lecturer and Consultant Orthodontist, Faulty of Dental Sciences, University of Peradeniya

(BDS, MS) Professor in Orthodontics, Division of Orthodontics, Faculty of Dental Sciences, University of Peradeniya.(BDS, PhD) Professor, Department of Basic faculty of Dental Sciences, University of PeradeniyaSenior Lecturer in Statistics, Department of Statistics and Computer Science, Faculty of Science, University of Peradeniya.

AbstractObjective: To assess the factors associated with the compliance of patients undergoing orthodon-tic treatment with removable and fixed appliances. Materials and methods: Sample of 60 orthodon-tic patients with removable and fixed appliances (32 females and 28 males) between 10 and 22 years of age (average age 14.5 ± 2.794 years) were selected with clinical compliance evaluation method and were evaluated using a questionnaire.

Results: There were statistically significant cor-relations between the age of the patient (p-value = 0.006), father’s education level (p-value = 0.049 and τ= 0.038), difficulties in practice oral hygiene measures (p-value = 0.007, τ= 0.54) and contribution from the supportive clinical staff (p-value<0.05,τ= 0.32) towards the compliance of orthodontic patients wearing fixed appliances. Further, feeling discomfort in public due to oral embarrassment (p-value <0.05,τ= 0.173) was statistically significant among patients with bet-ter compliance than who were treated with both removable and fixed appliances. No statistically significant relations were found between the sex, patient’s perceptions of their malocclusion, patient’s awareness of the malocclusions and patient’s relationship with orthodontist.

Conclusions: The results of the current study highlight the correlation between age, oral health

awareness, personal oral embarrassment due to irregularities of the teeth and contribution from the supportive staff are important indetermining the compliance to treatment.Key Words: Compliance, Co-operation, Ortho-dontic Patient

IntroductionThe successful outcome of the orthodontic treatment depends not only upon the knowledge and clinical competence of the orthodontist con-cerned, but also the co–operation of the patient1. The issue of patient compliance is a complex, multifactorial and wide ranging in nature. Com-pliance can be perceived by factors such as the perceived need of orthodontic treatment by both the patient and parent, the timing of treatment, personality characteristics of both patient and parent, duration and the type of treatment. Compliance can be assessed either by direct or indirect means2. Direct measurement of objective compliance in orthodontics was assessed in a very few studies using timing devices built into the re-movable appliances3-6. Indirect measures mainly comprise judgment of compliance by the patient or his/her guardians7. Personality tests have been used by a few investigators with the goal of being able to predict patient cooperation by identifying particular personality types8. The reported data by Gabriel8

, Clemmer and Hayes3, Sahm6 have given

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evidence of considerable discrepancies among the various methods of compliance assessment.The co-operative orthodontic patient has been described in many studies that identifies the pa-tient by demographic and personal characteristics, such as age, sex, social class, personality type and relationship to the orthodontic team9. According to some reviewed research studies, age is consis-tently and significantly associated with patient co-operation10,11,12. These studies reveled that patients of 12 years of age or slightly younger are more co-operative than older children. The gender of the patient is one of the easiest attributable variable to assess compliance. Three studies3,13,14 reported that girls were more co-operative than boys, whereas five studies4,10,11,15,16 found no differ-ence between the two sexes. The socioeconomic status of a patient is also found to be related to orthodontic patient’s co-operation. Two studies reported that patients in the lower middle or lower social classes are more co– operative than children in the upper social class. The successful practice of orthodontics significantly depends on the interaction between the orthodontist and the patient17. Relationship between the clinician and the patient in orthodontic practice can positively influence the treatment outcome by encouraging the patient to co–operate with the following pre-scribed instructions with regard to the appliance wear and maintenance of oral hygiene18. Family support for the patient to follow the given in-structions is also needed for successful outcome of treatment. Further, continuous encouragement and feedback from the orthodontic supportive staff is helpful to create supportive and friendly environment to the patient. These factors may further enhance the compliance of the patient towards orthodontic treatment17.

As compliance of a patient is a major contributory factor for the successful outcome of orthodontic-treatment, this study was designed to evaluate the factors associated with patient compliance in orthodontic treatment.

Aims and objectivesThis study was designed to determine following factors associated with the compliance of patients undergoing orthodontic treatment with removable and fixed appliances.

1. Age and sex

2. Socioeconomic factors of patient

3. Perception of malocclusion

4. Awareness of the malocclusion

5. Relationship with the team of orthodon-tics

Materials and methodsA descriptive, prospective and comparative study was conducted at the Division of Orthodontics, Faculty of Dental Sciences, University of Pera-deniya, Sri Lanka. The final study sample con-sisted of 60 orthodontic patients, which included 28 boys and 32 girls aged 10 to 22 years.The mean age of the sample was 14.5 years (SD±2.794years). Patients with cleft lip and palate, syn-dromic conditions and other serious disabilities were excluded from this study.

Initial assessment was done with 200 patients at the beginning of treatment with upper simple removable appliances (110 patients) and full fixed appliances (90 patients) by a single orthodontist. Clinical compliance assessment was performed four times for each appointment in monthly intervals by the principal investigator. Informed consent was obtained from the patients, and both patients and parents for those below the age of eighteen years.The two compliance groups were evaluated using the clinical compliance evalu-ation method19 which was designed to make a quantitative and objective appraisal of patient compliance. It examines three areas of co-opera-tion, oral hygiene, appliance wear and appliance maintenance.

Compliance of the patients wearing removable ap-pliance were assessed using a modified version of simplified oral hygiene index20 and 9-point scale

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of appliance wear19. In the modified version of simplified oral hygiene index, the facial surfaces of both maxillary permanent 1st molars, the maxillary right permanent central incisor, mandibular left permanent central incisor and lingual surfaces of both mandibular permanent first molars were used for assessment.

Right 1st molar

Rightpermanent

central incisor

Left perma-nent central

incisor

Left 1st molar

Buccal Lingual Labial Labial Buccal Lingual

Upper x x x

Lower x x x

Table 1: Assessment surfaces of modified version of simplified oral hygiene index The index included a 4-point scale consists following parameters.

4 points No debris or stain present

3 points Soft debris not covering more than 1/3 of the tooth surface or gingival to the bracket

2 points Soft debris covering more than 1/3 of the tooth surface, in-cluding the bracket, but not more than 2/3

0 point Soft debris covering more than 2/3 of the tooth surface, both gingival and incisal to the bracket

Table 2: Modified version of simplified oral hygiene indexAppliance wear was measured on a 9-point scale19 for removable appliance patients. The point values were based on the percentage of the prescribed time duration that the patient wore the appliance. The nine point scale for the assessment of removable appliance wear is included by following parameters. The assessment was based on the patient’s response and the judgmentof the clinician.

25 points 90% - 100% of the prescribed time



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15 points 60%- 70%of the prescribed time

12 points 50% - 60%of the prescribed time


6 points 30% -40%of the prescribed time



Table 3: The nine-point scale for the assessment of removable appliance wear

Compliance of the fixed appliance wearing patients were assessed using modified version of simplified oral hygiene index20as mentioned

above (Table1and 2) and 4-point scale of fixed appliance maintenance19which included follow-ing parameters.

25 points No broken brackets or bands and no bends in the arch wire

15 points No breakages or mild bends in the arch wire

5 points Moderate bends in the arch wire or loose bands

0 points Broken brackets, loose bands

Table 4: 4-point scale of fixed appliance maintenance

The total highest score was given for the patient either with removable appliance or fixed appli-ance was 29 points. Patients who were above (≥ 50%)and below(˂50%) the average of each assessment were considered as below average compliance (better compliers) and below average compliance (poor compliers) respectively.. Final-ly, 60 patients were selected for the final study sample including equal number of patients in each

category as in the following distribution (Fig.1). Half of these patients (30 patients) received treatment with simple removable appliances (RA) and the other half (30 patients) received fixed appliance (FA) treatment. Each group consisted of fifteen patients with below average compliance and fifteen patients with above average compli-ance according to the scoring given by the clinical compliance evaluation method.

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Parent sample

(200 subjects)

Patients with RA Patients with FA

(110 patients) (90 patients)

Assessment of compliance Assessment of compliance

Drop outs Drop outs

Above average Below average Above average Below average

Compliers Compliers Compliers Compliers

(15 patients) (15 patients) (15 patients) (15 patients)

Fig 1: Flow chart of sample selection

4-point scale of fixed appliance maintenance

Modified ver-sion of sim-plif ied oral hygiene index

Modified ver-sion of simpli-fied oral hy-giene index

9-point scale for assessment of appliance wear

The patients who were enrolled in the research project were asked to complete paper – pencil questioners. Initially a pilot questioner was conducted to seven subjects to determine the appropriateness, to identify ambiguous questions

and to measure the time for completion. The questionnaire was designed to include 27 items to obtain basic demographic information, five items to assess socio-economic factors of the patient and ten items to assess patient’s percep-

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tions of the malocclusion. Further four questions were added to assess the patient’s awareness of the malocclusion and six items were included to assess the level of relationship of the patient with the orthodontic team. The patients were informed about the confidentiality of data collection and were not made available for any other patients identity was concealed throughout the process.

ResultsThe scores obtained from each questioner were entered and analyzed using the statistical soft-ware R21.Data were analyzed using correlation tests and stepwise multiple regression analysis. Fisher’s exact test was indicated to assess the association between variables as the sample size is small. If the association between the variables are significant, the Kendall rank Correlation Coefficient test(τ) was applied to measure the ordinal association between the two variables. There was a positive correlation between the age of the patient and the compliance among subjects who were wearing fixed appliances (p-value = 0.006). Its positive correlation was confirmed with the Kendall rank Correlation Coefficient test (τ= 0.078). However, there was no relation-

ship between the gender and the compliance of the patients towards the orthodontic treatment (p-value = 0.43). A statistically significant posi-tive correlation was observed with regard to the father’s education level and the compliance of the subjects who were wearing fixed appliances (p-value = 0.049 and τ= 0.038).There was no significant association between the perception of their malocclusion and compliance towards orthodontic treatment (p-value >0.05). Signifi-cant correlation was observed with regard to the difficulty in practicing oral hygiene measures due to irregularity of teeth and the compliance of patients wearing both removable and fixed appliances (p-value = 0.007, τ= 0.54). This study didn’t show any significant association between patient’s knowledge of the irregularities of the teeth and their co-operation (p-value = 0.75). With the present study, a positive correlation was observed with removable and fixed appliance pa-tients with regard to the feeling of discomfort in public and the cooperation towards the treatment (p-value <0.05,τ= 0.173). Moderately positive association was observed between the supportive clinical staff and the compliance of the patients (p-value<0.05,τ= 0.32)

RemovableAppliances

FixedAppliances

TotalSample

No Variable p-value τ value p-value τ value p-value τ value1 Age 0.129 -0.195 0.006* 0.078 0.178 -0.0242 Sex 1.000 0.067 0.462 0.202 0.438 0.133

3 Father’s Educational level 0.792 -0.192 0.049* 0.004 0.125 -0.084

4 Mothers Educational level 0.605 -0.221 0.888 0.013 0.779 -0.085

5Patient’s perceptions of their malocclusion 0.256 -0.101 0.465 -0.072 0.076** -0.085

6 Feeling discomfort in public 0.224 0.333 0.483 0.000 0.089** 0.173

7 Difficulties in practice oral hygiene measures 1.000 -0.115 0.007* - 0.546 0.018* -0.335

8 Patient’s awareness of the malocclusions 0.545 -0.110 0.859 -0.084 0.758 -0.084

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9 Patient’s relationship with orthodontist 0.163 -0.029 0.674 -0.074 0.191 -0.046

10 Patient’s relationshipwith the supportive staff 0.857 0.0779 0.080** 0.327 0.183 0.230

*Significant at 95% and **significant at 90% Table 06; Summary of the data analysis

Fig 02; Correlogram shows the correlation among the variables of the patients treated with removable appliances

Fig 03;Correlogram shows the correlation amongthe variables of the patients treated with fixed appliances


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Fig 04;Correlogram shows the correla-tion among the variables of the patients in the total study sample

Discussion In the assessment of compliance of orthodontic patients, it is important to evaluate their demo-graphic characteristics. Some studies showed no correlation between the age and the level of compliance of orthodontic patients13. However, some studies have reported that patients have more co–operation towards orthodontic treatment below the age of 12 years than adolascents22.In one study10, the age was found to be the best predictor of compliance towards the orthodontic treatment. In agreement with latter studies, our study also showed a positive correlation between the age and co-operation towards orthodontic treatment with fixed appliances.

Some studies have claimed that patient’s gender might help to predict the compliance of patients towards orthodontic treatment. Girls were more co-operative than boys were the conclusions of a few studies3,13,14. How ever, some other studies highlighted that there is no significant correlation between gender difference and compliance of the patient to orthodontic. Present study also showed no significant correlation between the gender and compliance of orthodontic patients who had treatment with removable and fixed appliances.It is considered that the parent educational level

has a positive impact on their children’s coopera-tion towards the orthodontic treatment. In present study father’s educational level had positive effect on patient's better compliance.Therefore, it shows that educated parents are able to provide positive motivation to children for compliance with long term orthodontic treatment. Oral health awareness, specific dental knowledge and personal oral embarrassment are considered as positive motives associated with compliance of a patient7. Siddegowda and Rani23 found moderate level of knowledge and awareness of irregular teeth with co–operative patients. In the present study, patients who were wearing fixed appliances had significant correlation to compliance and the difficulty in practicing oral hygiene measures due to their irregularities. Fixed appliances are indi-cated for the management of complex orthodontic problems when compared to the indications for simple removable appliances. Therefore, the above correlation might be due to the complexity of the malocclusion. Some individuals may ex-perience personal oral embarrassment due to the unaesthetic appearance of irregularly arranged teeth. Therefore, sometimes they refuse to per-form activities in public. In the present study, it was shown that patients with better compliance had the feeling of discomfort in public especially who were indicated for fixed appliances. This also in directly showed that the severity of malocclu-sion has a positive correlation with compliance. Specific dental knowledge of the patients also considered as one of the positive motives for their co–operation. However, there was no such positive relationship in this study.

Relationship between clinician and supportive staff is an important factor in the compliance of the patient towards the treatment. Orthodontist’s behavior like listing, empathy and explanation of treatment to the patient are important in improving compliance of orthodontic patient24. The patient’s satisfaction and co–operation are influenced by politeness and verbal communi-cation between patient and whom may help to


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alleviate anxiety of the patient. In this study the moderately positive correlation was observed with the supportive staff and the compliance of the orthodontic patients (r= 0.032). However, there was no significant correlation between the relationship of the patient with the clinician and compliance.

ConclusionIn conclusion, the results of the present study on the assessment of factors associated with patient’s compliance in orthodontic treatment highlights correlation between age, oral health awareness, personal oral embarrassment due to irregularities of the teeth and contribution from the supportive staff of orthodontic team. Although a larger sam-ple is required, this study provides a baseline for a comprehensive study in the future. In a future study, it is important to objectively assess the se-verity of malocclusion as a factor that correlates to the compliance with orthodontic treatment.

AcknowledgmentsWe would like to thank all the orthodontic patients who participated in the study.

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Research Article I - Sri Lanka Dental Associationcontrol.slda.lk/media/sldj/47_01_2017/Ressearch_article_1_.pdf · undergoing orthodontic treatment with removable and fixed appliances