Development of a measure of hypodontia patients’ expectations of the process and outcome of combined orthodontic and restorative treatment

Abstract

Objectives

To devise and assess the psychometric properties of a measure that investigates hypodontia patients’ expectations of the process and outcome of combined orthodontic/restorative treatment.

Setting

Specialised secondary care facility for individuals with hypodontia.

Materials and methods

Mixed research design with three phases: (a) Thematic analysis of data from individual interviews with 25 hypodontia patients/16 parents to generate the questionnaire items. (b) Questionnaire design, assessment of readability and face/content validity with 10 patients. (c) Survey of 32 new hypodontia patients to determine the internal consistency of the measure.

Results

Three main themes related to the treatment process emerged from the qualitative data: ‘hypodontia clinic’, ‘orthodontic treatment’ and ‘restorative treatment’. Three main themes were also revealed relating to treatment outcome: ‘changes in appearance’, ‘psychosocial changes’ and ‘functional changes’. A 28 item questionnaire was constructed using a mix of visual analogue scale (VAS) and categorical response format. The Flesch reading ease score of the measure was 78, equivalent to a reading age of 9–10 years. Face and content validity were good. The overall Cronbach’s alpha was 0.80 while for the treatment process and treatment outcome subscales it was 0.71 and 0.88 respectively.

Conclusions

A patient-based measure of the process and outcome of combined orthodontic/restorative treatment for hypodontia patients has been developed which has good face and construct validity and satisfactory internal consistency.

Clinical significance

Patient expectations of treatment are important in determining not only their satisfaction with treatment outcomes but also their engagement with the clinical process. This questionnaire is a first step in operationalising the expectations of hypodontia patients through assessment tools that can then determine whether pre-treatment counselling is required and aid the consent and treatment planning process, thus improving the quality of treatment provided by approximating the expectations the patients hold to their actual experience.

Introduction

Patients’ expectations are critical determinants of their satisfaction with treatment and unrealistic expectations may indicate the need for additional support . Whereas previous research has explored the expectations of patients seeking orthodontic and restorative treatment , to date there are no published studies exploring the expectations of individuals with hypodontia of their pathway of care.

Hypodontia not only has a potentially long lasting and serious impact on an individuals’ quality of life, but also requires complex multidisciplinary treatment over a protracted period which may be difficult to comprehend initially by the patients and their carers .

To address this lack of understanding of hypodontia patients, the present study aims to:

  • 1.

    Explore the expectations and experiences of hypodontia patients of the process and outcome of their combined treatment.

  • 2.

    Devise a measure that investigates hypodontia patients’ expectations of the process and outcome of treatment.

  • 3.

    Assess the psychometric properties of the measure.

Materials and methods

Mixed methods research design with three phases: (a) Thematic analysis of data from individual interviews with 25 hypodontia patients/16 parents to generate the questionnaire items. (b) Questionnaire design, assessment of readability and face/content validity with 10 patients. (c) Survey of 32 new hypodontia patients to determine the internal consistency of the measure.

Ethical approval was obtained from the National Research Ethics Committee London – Chelsea, REC Reference number: 13/LO/1146.

Phase one: patient interviews

Participants for the individual interviews were all patients attending a specialist hypodontia service at a secondary care facility, and were drawn from three groups:

  • Patients with no previous experience of orthodontic or restorative treatment.

  • Patients who were nearing the end of the orthodontic phase of treatment.

  • Patients who had completed the restorative phase of treatment.

It was considered necessary to interview patients at different points in the treatment process to be able to gauge the full range of expectations from the viewpoints of those who never had treatment and from those who experienced some or all of the treatment as those who had experience of treatment would be able to discuss aspects of treatment with unformed expectations at commencement.

The inclusion criteria were:

  • Patients and their parents/‌carers, of any ethnicity,

  • Able to speak English at the level required for a typical consultation,

  • Aged 10 years and above. Patients attending the hypodontia clinic are typically aged from 10 years. It was felt important to capture the expectations and experiences of the full range of patients.

Patients were excluded from the study if they presented with an accompanying craniofacial abnormality.

Data saturation from the on-going analysis of themes guided the final sample size. No new themes emerged from the data after 25 patients were interviewed. In order to recruit these 25 patients, 48 patients were approached with 23 declining to participate. (See Table 1 for patient characteristics). One of the male and 15 of the female participants were accompanied by a parent /guardian.

Table 1
Participants’ characteristics – patients only (n = 25).
Male n(%) Female n(%) TOTAL n(%)
Stage of Treatment
Pre-treatment 4 (40%) 6 (60%) 10 (40%)
Mid-treatment 3 (27.3%) 8 (72.7%) 11 (44%)
Post-treatment 1 (25%) 3 (75%) 4 (16%)
Age group (yr)
10–18 7 (43.8%) 9 (56.2%) 16 (64%)
>18 1 (11.1%) 8 (88.9%) 9 (36%)
Severity of hypodontia
Mild 4 (66.7%) 2 (33.3%) 6 (24%)
Moderate 1 (10%) 9 (90%) 10 (40%)
Severe 3 (33.3%) 6 (66.7%) 9 (36%)
Site of Hypodontia
Anterior 3 (42.9%) 4 (57.1%) 7 (28%)
Posterior 2 (25%) 6 (75%) 8 (32%)
Anterior and posterior 3 (30%) 7 (70%) 10 (40%)
Total number of males/females 8 (32%) 17 (68%) N = 25 (100%)

Procedure: A single researcher (AB) conducted the interviews and had no involvement in the treatment of the hypodontia patients during that time. The interviewer is a qualified orthodontist who has good knowledge in the treatment of the hypodontia patient. The interviews lasted 30–60 min on average.

The interviews took place in a room separate to the waiting area and if patients were under 16 years, parents/guardians were also required to attend. The new and in treatment participant interviews were aimed at identifying what the patients expect from the process and outcome of the combined treatment they are yet to receive, while the end of treatment participant interviews focused on their experiences of the combined treatment they had received as a whole, in addition to their perceptions of the treatment outcome and the relationship of these views with their initial expectations (Please see Appendix A in Supplementary material for the topic guide).

Transcription and coding: All the interviews were recorded, transcribed and entered into the QSR NVivo 10 software to facilitate data analysis. Thematic analysis was undertaken which comprises of identification and reporting patterns of themes or groups of meanings within the data. This allows the systematic categorization of the data into higher-order key themes addressing the overall research question. Data analysis combined both inductive and deductive elements, drawing on the existing literature on expectations to derive categories deductively, as well as inferring novel categories from the data.

To ensure the reliability of the data, each transcript was independently coded by at least two members of the research team. Analysis of themes occurring in the interviews proceeded in parallel with the interviews until no new topics arose (data saturation).

Phase two: development of the questionnaire

Questionnaire content: On the basis of the themes, sub-themes and elements identified in the qualitative interviews and the frequency of occurrence of each theme, together with expectation items drawn from existing questionnaires , a total of 28 items were written for use in the following domains: hypodontia clinic (3 items, 7 sub-items), orthodontic treatment (3 items, 7 sub-items), restorative treatment (9 items, 5 sub-items) and benefits of treatment (2 items, 14 sub-items). The full scale can be found in Appendix B in Supplementary material. The questionnaire posed the items in two parallel formats. Those participants completing the questionnaire prior to their appointment are given the wording “… do you expect to have?” whereas those who received it after their appointment had the wording “…did you actually have?”. This enables the comparison of expected versus actual experience.

An additional personal information section (10 items) was added to the beginning of the questionnaire. The final draft was divided into five sections of which three sections were questions about treatment process and one section about treatment outcome:

A. Personal information

Expectations of treatment process

B. Hypodontia clinic

C. Orthodontic treatment

D. Restorative treatment

Expectations of treatment outcome

E. Benefits of treatment

The questions adopted either a VAS or multiple choice response formats. The questionnaire was professionally printed on A4 size paper and the front cover was designed with a colourful logo to be visually appealing and inviting to the respondents , the following page provided the directions for use. The questionnaire itself comprised 11 pages with individual sections demarcated by bold headings.

Pilot testing the questionnaire : The first version of the questionnaire was piloted on a purposive sample of 10 new patients/parents over a period of two weeks. Face and content validity, along with ease of comprehension, were assessed by using the thinking aloud technique where participants discussed their experience of filling in the questionnaire with the researcher as they completed it . Any queries or areas that posed difficulty to the respondent or that were not answered were recorded, along with the duration of time taken to complete the survey. Microsoft Word © was employed to test the readability of the survey according to the Flesch Reading Ease score and Flesch-Kincaid grade.

Phase 3: testing the reliability of the questionnaire

A total of 40 consecutive new hypodontia patients were invited to participate; inclusion criteria were: 14 years and above and able to read and speak English at a reading level of 12 years. Participants affected by other craniofacial conditions were excluded. The patients were asked to complete the questionnaire themselves in the waiting room before their consultation appointment in the hypodontia clinic. The responses were entered into SPSS© and Cronbach’s alpha (α) was calculated (Bowling, 2002). Only the VAS questions were included in the calculation. Items in the Demographics section were not included, as were the following individual items: Treatment Process: Hypodontia clinic questions (B.1, B.2, B.3), How long do you think orthodontic treatment will take (C.3.c), Do you expect to receive restorative treatment (D.1), and, what type of tooth replacement do you expect to have to fill the gaps (D.2).

Three values of Cronbach’s alpha were calculated: Whole scale (items from sections B, C, D and E); Process subscale (items from section B, C, D); Outcome subscale (items from section E).

Materials and methods

Mixed methods research design with three phases: (a) Thematic analysis of data from individual interviews with 25 hypodontia patients/16 parents to generate the questionnaire items. (b) Questionnaire design, assessment of readability and face/content validity with 10 patients. (c) Survey of 32 new hypodontia patients to determine the internal consistency of the measure.

Ethical approval was obtained from the National Research Ethics Committee London – Chelsea, REC Reference number: 13/LO/1146.

Phase one: patient interviews

Participants for the individual interviews were all patients attending a specialist hypodontia service at a secondary care facility, and were drawn from three groups:

  • Patients with no previous experience of orthodontic or restorative treatment.

  • Patients who were nearing the end of the orthodontic phase of treatment.

  • Patients who had completed the restorative phase of treatment.

It was considered necessary to interview patients at different points in the treatment process to be able to gauge the full range of expectations from the viewpoints of those who never had treatment and from those who experienced some or all of the treatment as those who had experience of treatment would be able to discuss aspects of treatment with unformed expectations at commencement.

The inclusion criteria were:

  • Patients and their parents/‌carers, of any ethnicity,

  • Able to speak English at the level required for a typical consultation,

  • Aged 10 years and above. Patients attending the hypodontia clinic are typically aged from 10 years. It was felt important to capture the expectations and experiences of the full range of patients.

Patients were excluded from the study if they presented with an accompanying craniofacial abnormality.

Data saturation from the on-going analysis of themes guided the final sample size. No new themes emerged from the data after 25 patients were interviewed. In order to recruit these 25 patients, 48 patients were approached with 23 declining to participate. (See Table 1 for patient characteristics). One of the male and 15 of the female participants were accompanied by a parent /guardian.

Table 1
Participants’ characteristics – patients only (n = 25).
Male n(%) Female n(%) TOTAL n(%)
Stage of Treatment
Pre-treatment 4 (40%) 6 (60%) 10 (40%)
Mid-treatment 3 (27.3%) 8 (72.7%) 11 (44%)
Post-treatment 1 (25%) 3 (75%) 4 (16%)
Age group (yr)
10–18 7 (43.8%) 9 (56.2%) 16 (64%)
>18 1 (11.1%) 8 (88.9%) 9 (36%)
Severity of hypodontia
Mild 4 (66.7%) 2 (33.3%) 6 (24%)
Moderate 1 (10%) 9 (90%) 10 (40%)
Severe 3 (33.3%) 6 (66.7%) 9 (36%)
Site of Hypodontia
Anterior 3 (42.9%) 4 (57.1%) 7 (28%)
Posterior 2 (25%) 6 (75%) 8 (32%)
Anterior and posterior 3 (30%) 7 (70%) 10 (40%)
Total number of males/females 8 (32%) 17 (68%) N = 25 (100%)
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Jun 19, 2018 | Posted by in General Dentistry | Comments Off on Development of a measure of hypodontia patients’ expectations of the process and outcome of combined orthodontic and restorative treatment
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