P atient noncompliance can limit the effective conversion of accurate orthodontic treatment plans to excellent treatment results. Factors related to noncompliance are wide ranging. Initially, these factors may be related to the patient’s personal experiences in the dental office or the patient’s perceptions based on the experiences of family or peers. Patients often avoid dental treatment completely because of “dental anxiety.” Anxiety can lead to a fear of future orthodontic appointments and procedures, causing problems at the chair side for placing or applying different orthodontic appliances or procedures. Chair-side anxiety can be modified by good communication and patient education regarding procedures. Once the patient overcomes this initial anxiety, the orthodontist and staff can focus on obtaining patient compliance in oral hygiene and appliance wear.
Orthodontic treatment processes require changes in established individual routines and also affect different social activities. Behavior modification to accommodate new demands placed by orthodontic techniques and appliances may involve changes that range from simple to extremely complex. Decreasing the complexity of the required behavior change may lead to better compliance. Also, because most patients are in the adolescent age group, they present with a unique process of changing from parental values toward acceptance of peer-group standards. Not surprisingly, studies have shown better compliance in patients under age 12 years than in older groups. Although important, this fact may not effectively predict or improve patient compliance.
This chapter discusses different factors that influence orthodontic patient compliance and provides strategies to improve compliance.
TREATMENT TECHNIQUES TO AVOID COMPLIANCE ISSUES
A variety of orthodontic treatment techniques have been devised to overcome the noncompliance barrier in the attempt to obtain good results. Despite earlier claims by the proponents of these techniques, none is completely successful without the patient’s partial or complete participation. Further, many of these so called noncompliance techniques have now reverted back to traditional methods of anchorage control, using headgear and elastics for part of the treatment period.
Orthodontic anchorage control has evolved over the years, and use of bone-borne anchors is now widespread. These temporary anchorage devices (TADs) provide solutions to difficult situations and in some cases simplify compliance needs. Further, innovative orthodontic tools and refined treatment protocols have also improved the overall efficiency of the orthodontic treatment process. However, addressing issues of appliance breakage, elastic wear, and oral hygiene always requires discipline and compliance.
INFLUENCE OF FACIAL ESTHETICS
Perceived improvement of facial esthetics or cosmetic change may be the main reason why patients and parents seek orthodontic treatment. Functional considerations do not necessarily correspond to the patient’s desire for orthodontic treatment. Often, professional assessments differ from the parent’s or patient’s assessment of the need or severity of malocclusion or the need for orthodontic treatment. Epidemiological studies show that more than 70% of the population could benefit from orthodontic correction of occlusal functional discrepancies.
Cultural and maturational differences exist in how individuals associate dentofacial attractiveness to overall esthetics and self-esteem. However, most patients view orthodontic treatment as a means to improve dentofacial esthetics. Significant changes are observed daily in people’s self-esteem through minor or major orthodontic correction. These positive changes can have a significant impact in people’s daily lives. During orthodontic pretreatment consultation, patients frequently comment on their inhibition toward a natural smile because of the malalignment of their dentition. Therefore these positive changes (or the expected changes) may be used to motivate the patient’s compliance.
A clinical “pearl” to remember is to use facial esthetic changes to motivate and sustain the patient’s overall compliance.
INFLUENCE OF FACIAL ESTHETICS
Perceived improvement of facial esthetics or cosmetic change may be the main reason why patients and parents seek orthodontic treatment. Functional considerations do not necessarily correspond to the patient’s desire for orthodontic treatment. Often, professional assessments differ from the parent’s or patient’s assessment of the need or severity of malocclusion or the need for orthodontic treatment. Epidemiological studies show that more than 70% of the population could benefit from orthodontic correction of occlusal functional discrepancies.
Cultural and maturational differences exist in how individuals associate dentofacial attractiveness to overall esthetics and self-esteem. However, most patients view orthodontic treatment as a means to improve dentofacial esthetics. Significant changes are observed daily in people’s self-esteem through minor or major orthodontic correction. These positive changes can have a significant impact in people’s daily lives. During orthodontic pretreatment consultation, patients frequently comment on their inhibition toward a natural smile because of the malalignment of their dentition. Therefore these positive changes (or the expected changes) may be used to motivate the patient’s compliance.
A clinical “pearl” to remember is to use facial esthetic changes to motivate and sustain the patient’s overall compliance.
FACTORS AFFECTING ORTHODONTIC PATIENT COMPLIANCE
During the initial treatment stages the parent’s positive attitudes toward perceived changes resulting from orthodontic treatment predict patient compliance. In the later stages the patient’s own perception regarding treatment and outcomes directly correlates with compliance levels. Patients show better compliance when they believe their actions directly lead to superior treatment results than when they believe they have no control over treatment outcomes.
Different patient, parent, and practitioner variables have been correlated with orthodontic patient compliance. Patient variables range from different demographic factors to personality type and desire for treatment. The parent’s previous orthodontic experience can have a positive influence on patient compliance. If an increase in fees for noncompliance occurs during orthodontic treatment, parental influence on the child’s performance may influence future compliance. Studies have shown that doctor-patient rapport can significantly influence patient satisfaction and compliance.
Factors found to correlate with patient compliance have not shown any particular trend. Studies have largely been inconclusive, or the results have not been reproducible. This inconsistency has forced practitioners to develop different methods for improving compliance. Depending on the practice or the patient, these methods range from punishment for poor compliance to rewards for better compliance.
Results of demographic studies may clarify some of the reasons for noncompliance but do not provide solutions to improve compliance, because practitioners cannot change these demographics for their patients. Therefore the focus of research efforts has been on areas outside the practitioner’s influence or parental/patient influence. Also in this context, “prediction” may not necessarily lead to prevention. The emphasis should be on prevention or improvement of noncompliance rather than relying on demographics or predictions of expected behavior. Along with other solutions, this chapter discusses different prevention and improvement concepts that can positively affect orthodontic patient compliance.
The paradigm shift from a practitioner-centered model of patient care to a patient-centered approach is occurring in all areas of health care. In current orthodontic practice the patients and parents are more informed about their condition and treatment needs. More resources are available to obtain information on orthodontic treatment as well as the practitioner from a variety of Internet locations. This can be viewed as a positive change to disseminate information regarding orthodontic practice and patient care. The increase in parent/patient knowledge about orthodontic treatment influences day-to-day orthodontic work. Increased patient involvement has switched the traditional practitioner-centered care to a patient-centered approach.
PATIENT-CENTERED ORTHODONTIC TREATMENT
Traditionally, orthodontic treatment was prescribed by the practitioner based on defined professional standards, without considering the priorities and capabilities of the patient. Understanding this concept requires evaluation of the initial examination, diagnosis, and treatment-planning process.
During the selection of treatment techniques and appliances, the practitioner-centered plan uses tools to treat patients with the assumption of patient acceptance. Patients who fail to follow prescribed instruction are labeled as “noncompliant,” often without considering that the treatment prescribed may not have taken into account the capabilities, motivations, and expectations of the individual patient. Thus, patients endure the outcome of “noncompliance” rather than considering the inability of the practitioner to understand individual patient needs and make appropriate treatment plans.
A patient-centered approach places some of the responsibility of successful patient compliance on the practitioner. In this model the practitioner prescribes treatment plans based on individual patient expectations, priorities, and most importantly the patient’s capabilities.
Repeated treatment progress evaluation and patient-parent consultation are key components of success in this proposed model. Orthodontic treatment planning should emphasize patient education, empowerment, and contracting procedures.
Patient Education
Patient management works better when patients understand the nature of their condition and the proposed treatment plan or procedure. Educating patients regarding their malocclusion or condition and the means to obtain acceptable results are important measures in successfully motivating patients to succeed. In many cases, treatment is prescribed for patients who have limited understanding of their orthodontic problem and the need for certain appliances or mechanics to achieve a successful outcome. At the same time, parents may be unclear about treatment goals and mechanics. Further, the parent’s ability to explain details of the condition and the necessity for different appliances to their children may be limited as well. The result is a patient who is less likely to have a successful treatment outcome because they cannot associate cause and effect. Also, in many cases, alternative strategies have not been discussed as options for patients and parents in deciding what would work for the patient.
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