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


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.


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.


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.


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


  • Q methodology was used to assess the concerns of adults.

  • Individualized intervention was used in relation to the results of Q methodology.

  • Participants were randomized into 2 groups.

  • The State-Trait Anxiety Inventory was used to measure the changes in anxiety level.

  • Individualized interventions can reduce anxiety in adult orthodontic patients.

Dental anxiety is a widespread problem that may deter patients from seeking dental care. Dentally anxious persons often have poor dental health because of their avoidance behaviors. Dental anxiety may also affect them more generally through negative thoughts, fears, sleep disturbance, and interferences with work and personal relationships. Concerns relating to the discomfort of the initial phase of orthodontic treatment and the psychosocial implications of wearing braces can cause high levels of anxiety, Anxious patients may miss appointments and have poor compliance. Many reports in the orthodontic literature have shown high anxiety levels in patients undergoing orthodontic treatment.

Recently, several authors have investigated specific solutions for managing self-reported pain and anxiety in a sample of orthodontic patients. Wright et al found that supplementing verbal information with written information resulted in improved motivation for orthodontic treatment, but there was no statistically significant effect on anxiety, apprehension, or patient compliance. Bartlett et al found that a telephone call from a health care provider reduced patients’ self-reported pain and anxiety. Keith et al showed that a text message from an orthodontic office after initial appliance placement resulted in a lower level of patient self-reported pain, but anxiety did not change. However, a review of these studies indicated that the effects of these methods leave considerable room for improvement.

Q methodology is a research method that combines qualitative and quantitative methods, allowing data to be viewed from a subjective perspective. Subjective perspectives are defined by internal factors, such as interpersonal relationships, individual attitudes, perceptions, feelings, and opinions, rather than external factors. Q methodology is based on the assumption that subjectivity will be expressed by a person’s behavior, as reported through the ranking of specific statements.

Q methodology involves generating a sample of statements about a topic, which are then ranked by respondents. The final phase of this technique involves Q analysis and factor interpretation. Q methodology has been used in the social sciences, art, religion, education, psychology, and medicine. However, its use in dentistry has been limited. Schabel et al found that Q sort was more reliable than the visual analog scale for measuring smile esthetics. Prabakaran et al demonstrated that the most common motivation of adolescents seeking orthodontic treatment was esthetics, whereas for their parents, it was preventing future problems caused by malocclusions. Davis et al identified 4 factors that captured the motives of most parents who sought orthodontic treatment for their children: well-timed treatment to prevent future dental problems, parental responsibility, perceived benefits, and perceived need instilled by the dentist. Two studies used Q methodology to examine dentists’ attitudes toward prevention guidance and establishing a toothbrushing program. In previous studies, we used Q methodology to assess the concerns and motivations of women seeking orthodontic treatment and identified major factors related to concerns and motivations. However, these previous studies identified factors related to the topic; this study is the first attempt to use Q methodology to solve problems associated with identified concerns.

The aim of this study was to use Q methodology to assess the concerns of adults seeking orthodontic treatment and to investigate the influence of individualized interventions based on these concerns about self-reported anxiety in a sample of orthodontic patients.

Material and methods

This was an explorative interview and questionnaire study. All participants were recruited on their first visit to the orthodontic department of Wenzhou Medical University, Wenzhou, China, between October 2013 and May 2014. Participants were adults aged over 18 years of age. Exclusion criteria were cleft lip or palate, prosthodontic or orthognathic needs, craniofacial syndromes, learning disabilities, and excessively high levels of anxiety (trait-anxiety scores ≥56 for men and ≥57 for women; state-anxiety scores ≥53 for men and ≥55 for women), because these patients did not represent the typical orthodontic population. Ethics approval for the study was granted by the health research ethics board at Wenzhou Medical University (WYKQ2013015). All participants provided signed informed consent.

Q sampling begins with development of opinion statements, involving the collection of a wide range of views on the topic under investigation. In this study, a Q sample was constructed through interviews. Two researchers received training in in-depth interviewing. The demographics of the patients (n = 70) who provided opinion statements are shown in Table I . These patients were selected from the university’s orthodontic department, using the inclusion and exclusion criteria described above. All 70 patients were interviewed in depth for generation of the statements; we asked the patients what they were concerned or worried about in the physical, psychological, and social aspects of orthodontic treatment and why. The interviews generated a list of 73 viewpoints about obstacles to adults seeking orthodontic treatment, and what they worried about before seeking orthodontic treatment. Next, 3 professors of orthodontics and 3 methodologists identified repeated viewpoints and eliminated duplications. Finally, 41 statements (the Q sample) were created to represent patients’ opinion statements ( Table II ). To test reliability, the Q sample was retested by 100 randomly selected adults, recruited using the established inclusion and exclusion criteria. They were completely new patients, recruited from the waiting list at the orthodontic department of the university before October 2013. These patients were asked to select their concerns about orthodontic treatment from the opinion statements. In total, 99% of their concerns were located in the opinion statements.

Table I
Demographics of adult patients providing opinion statements and P-sample
Demographic Patients providing opinion statements (n) P-sample (n)
Age (y)
18-24 27 14
25-35 32 22
>35 11 4
Male 25 13
Female 45 27
Level of education
Illiterate and primary school 7 5
Secondary school 13 10
Tertiary 50 25
Urban 38 22
Rural 32 18
Student 10 4
Unemployed 10 4
Employed 50 32
Marital status
Single 41 24
Married 29 16
Total 70 40

P-sample , the participants sample.

Table II
Statements and factor scores
Statement Factor
1 2 3 4 5
1 I am hesitant all the time. 0 3 −2 −2 3
2 I am too busy with work or study and don’t have enough time to undergo the treatment. −1 −3 3 †,‡ −3 1
3 I am afraid that I cannot comply with the treatment. 0 −1 2 1 −1
4 I am afraid that I may not keep the appointments. 0 −2 −2 2 1
5 There is not enough time to undergo the treatment because I am planning on marriage and having children. −4 1 0 −1 3 †,‡
6 I am worried about pain during orthodontic treatment. 1 2 −1 2 −1
7 I am afraid of pain during tooth extraction. −1 1 −2 3 †,‡ 0
8 I think orthodontics is not very hygienic. −2 −3 −4 −1 −2
9 I am afraid I will look unattractive with braces. −2 0 4 †,‡ −4 2
10 I am worried about what other people think. −3 −2 1 −2 0
11 My place is far from the hospital. −3 2 5 †,‡ −1 −5
12 I will not feel comfortable if I wear braces as it will make me look different from others. −1 −3 0 0 −2
13 I think the price of the treatment is too high. 4 5 −3 −5 3
14 I am afraid that the treatment will be too complicated. 3 ∗,‡ 0 4 ∗,‡ 0 0
15 I have a fear of orthodontic treatment. 2 −4 −1 4 †,‡ 1
16 I am worried that the treatment time will be excessively long. 3 5 3 2 4
17 I think I am too old for orthodontic treatment. 1 4 0 5 1
18 I cannot afford treatment. 1 1 −4 −4 2
19 I am worried about orthodontic treatment because I do not have enough knowledge in this area. 5 †,‡ −1 1 3 2
20 I have poor health, and the treatment will make it worse. −5 −3 −5 −2 −4
21 I never realized that my teeth are irregular. −2 −5 −2 0 −5
22 I am afraid that this orthodontic technology may not be adequate. −1 −2 −2 −2 2
23 Other doctors do not recommend orthodontic treatment. −4 −4 −5 −5 −3
24 My family and (or) friends object to the treatment. −4 2 −4 −3 −3
25 I am afraid the treatment will affect my eating during the process. 3 0 3 −1 −4
26 I am worried that the treatment will be ineffective. 4 1 1 4 4
27 I am worried that the treatment may have some side effects. 2 0 −3 0 5 †,‡
28 I am afraid that the extraction will increase the space between my teeth. 0 0 −1 3 †,‡ −1
29 I am worried about that I am too old for treatment because my teeth will get loose and fall out early. 3 4 −1 5 3
30 I am afraid that the treatment will affect my future chewing and eating. 2 1 1 1 −1
31 I am afraid that my teeth will relapse and recur after treatment 5 4 −1 3 ∗,‡ 4
32 I am worried that after treatment I will lisp. 0 −1 0 1 −2
33 It is bothersome having to brush my teeth every time I finish eating. 4 2 3 −3 −3
34 I am afraid that I will have nicknames because of the braces. −5 −4 −3 −4 0
35 I am afraid the treatment will cause me to lose appetite. 2 −1 2 −1 −4
36 I am worried that wearing braces will hurt my mouth. 1 3 4 2 −3
37 I am afraid that I will not be able to speak perfectly with the braces. 1 −1 5 †,‡ 1 1
38 I am scared of dental procedures. −1 −2 −3 4 †,‡ −1
39 I am worried that the braces will lower my chances of finding a partner. −3 3 1 −3 5 †,‡
40 I am afraid that food will remain stuck in my teeth after eating. −2 3 2 1 −2
41 I am afraid the treatment will affect my performance at work. −3 −5 0 0 0

Note: The values “–5 to +5” mean “most disagreement to most agreement” with the statements. The agreement or disagreement with the distinguishing statements was statistically stronger in some factors than in others. Distinguishing statements that are significant at P <0.05 are indicated with an asterisk (*), and those at P <0.01 with a dagger (†). The 9 most concerning statements in each factor.

Brown recommended that 40 to 60 participants are adequate, with selection of the P-sample (participants sample) guided by the aim of maximizing the possibility that a variety of perspectives are expressed. In our study, 40 adults were recruited, using the established criteria. Patient demographics are shown in Table I . This sample was a different group from that used for the Q sampling.

Participants were given a randomized stack of 41 Q sample cards on each of which was written 1 patient opinion statement from the Q sample and a sorting instruction sheet that included a demographic information form. First, participants were instructed to read all statements. Second, they were asked to sort the statements into 3 piles: agree, disagree, and neutral. Third, participants were asked to place the statements on an 11-point distribution column ( Fig 1 ), placing statements they felt were most relevant to them in the far-left column (+5) and the least relevant statements in the far-right column (−5). Finally, they were asked to complete the central columns by choosing the remaining statements that were more and less relevant to them. This process was repeated until all remaining statements were placed in the neutral central columns. Participants were instructed to take as much time as they needed until they were comfortable with their final sorting. PQMethod (version 2.35; Peter Schmolck) was used to enter and analyze the data. Factors were extracted using centroid factor extraction and varimax rotation. We compared the rotations for 3 to 6 factors, choosing the most adequate solution. These factors represented at least 4 or 5 investigators, and the eigenvalues greater than 1 were extracted. A composite Q sort (sorting of statements) was created for each factor. These Q sorts responded in essentially the same ways and reflected an overall Q grid for a typical participant profile that loaded to that particular factor. Within each factor, there were distinguishing statements with which a particular factor agreed or disagreed statistically more strongly than other factors.

Fig 1
Eleven-point scale.

The sample size for each group was calculated as n = 67 (ie, a total of 134 for the 2 groups), based on type II error at 0.10 (90% power) with a 5% significance level, to detect a clinically meaningful difference of 5 points (SD, 8.0) in the State-Trait Anxiety Inventory (STAI). To account for possible dropouts and losses to follow-up, we recruited 160 eligible first-visit patients (80 patients for each group). These patients were randomized into an intervention group and a control group via a computer-generated sequence performed by a statistician. The randomization sequences were stored in opaque envelopes by a nurse who was not involved in this study. The outcome evaluators and statisticians were blinded to the allocation. Two senior orthodontists (F.L., Z.N.) were recruited and trained to provide interventions according to Q sorting and identified factors. Two other orthodontists in different rooms to prevent contamination administered control group treatments. The participants were also blinded to the allocation.

In the Intervention group, Q sorting was performed by new participants, conducted by an investigator. Each participant’s Q sorting was added in the previous 40 analyzed data, and they were then loaded onto the most appropriate factors using professional statistical software for Q methodology (PQ method). Two senior orthodontists delivered a personalized communication and treatment plan to all patients to address the 9 statements causing the most concern according to the Q sorting. Furthermore, the positive statements (statement value >0) from the individual sorting were considered together. Distinguishing statements (statement value >0; P <0.05) also were considered for patients loaded onto the 5 factors. The senior orthodontists were trained to standardize the intervention procedure according to the individualized statement sorting. For example, participants loaded onto factor 1 were mostly worried about the lack of information about orthodontic treatment and relapse. In this situation, orthodontists improved their communications with patients and provided more information about orthodontic treatment procedures and relapse, until the participants received the expected information. For participants worried that their family or friends might object to the treatment, the orthodontists communicated with the patient’s family and friends as appropriate to help them understand the treatment. When participants were worried about the cost and time of orthodontic treatment, the orthodontists were asked to consider shorter, more conveniently timed appointments and control the cost of treatment without affecting the curative effect. For those who were worried about speaking and their appearance with braces, the orthodontists chose appliances that were less visible and did not affect enunciation. For participants primarily concerned about pain, ibuprofen was used to alleviate pain, and for those primarily worried about dental fears, cognitive restructuring and systematic desensitization was used to alleviate anxiety and fear. Concerns that braces would lower the chances of finding a partner and that the treatment would have side effects were managed by the provision of more information about orthodontic treatment side effects. Explanations were also offered to help these participants understand that orthodontic treatment may make them look more attractive but can neither help them find a partner nor lower their chance of finding a partner. The interventions that were designed after Q sorting aimed to enhance communications based on the participants’ Q sorting and were carried out before treatment. The interventions were continued until the concerns of patients were resolved.

Control group participants received routine treatment from 2 senior orthodontists (F.L., Z.N.).

To reduce orthodontist bias, the 4 senior orthodontists involved in the study had similar demographic characteristics and work experiences.

Statistical analysis

The questionnaires comprised anxiety scales that assessed participants’ psychological status and personal information questions by collecting demographic information such as age, sex, education, region, marital status, and occupation.

The STAI was used to measure changes in participants’ anxiety levels before and during treatment. The STAI, developed by Spielberger, is a self-reported measure of state anxiety (how one feels at a particular moment, such as a dental visit) and trait anxiety (how one usually feels). Each scale contains 20 statements with responses on a 4-point Likert scale; the state anxiety score is based on 20 items for which respondents rate anxiety on a scale from 1 (not at all) to 4 (very much so). The trait anxiety score is based on 20 questions designed to measure anxiety on a scale from 1 (almost never) to 4 (almost always). The total scores of each scale range from 20 to 80, with higher scores suggesting greater levels of anxiety. The STAI has been validated in a Chinese population. Participants completed state anxiety inventory questions before meeting the orthodontic clinician (T1), before bonding (T2), 24 hours after bonding (T3), 7 days after bonding (T4), 4 weeks after bonding (T5), and 12 weeks after bonding (T6). Trait anxiety inventory questions were administered at T1, T5, and T6.

Statistical analyses were performed with SPSS software (SPSS for Windows, version 15.0; SPSS, Chicago, Ill). Independent-samples t tests were used to compare intergroup differences. A 1-way analysis of variance with a least significant difference post hoc test was used to assess intragroup STAI scores. Before these tests, Kolmogorov-Smirnov and Levene tests were used to check for normality and equality of variances. No significant differences were found among variances. The internal consistency of the 2 STAI scales was evaluated using Cronbach alpha coefficients. The level of statistical significance was set at P <0.05.

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Dec 19, 2018 | Posted by in Orthodontics | Comments Off on Individualized intervention to reduce anxiety in adult orthodontic patients based on Q methodology
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