Introduction
The primary aim was to compare patients’ and parents’ orthodontic treatment expectations at the Eastman Institute for Oral Health, University of Rochester, Rochester, NY (UR) in the United States. Secondary aims were to assess the association between sociodemographic factors and UR participants’ expectations; and compare participants’ expectations between UR, Academic Centre for Dentistry Amsterdam (ACTA) and King’s College Dental Hospital, London, United Kingdom (KC) (previously published data).
Methods
One hundred and forty participants [70 patients and one of their parents (n = 70)] completed a validated questionnaire (10 questions) to measure orthodontic treatment expectations before screening at the Orthodontic Department at UR. Various sociodemographic factors were assessed. The paired t test (for continuous responses) and the Fisher exact test (for categorical responses) were used to compare UR patients’ and parents’ responses. Two-sample t test and the Fisher exact test were used to compare participants’ responses among sociodemographic groups. One-way analysis of variance followed by the Tukey test, and the Fisher exact test were used to compare participants’ responses between UR, and ACTA and KC (data collected from previous publications). A multiplicity correction was performed to control the false discovery rate.
Results
Patients at UR expected less check-up and diagnosis, and less discussion about treatment at the initial visit, more dietary restrictions, and less improvement in smile esthetics and social confidence with orthodontic treatment than parents. Participants’ responses differed by sociodemographic factors at UR and between UR, ACTA, and KC.
Conclusions
Expectations of orthodontic treatment differ between patients and their parents, are associated with sociodemographic factors, and vary among United States and European University centers.
Highlights
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A validated questionnaire was used to measure orthodontic treatment expectations.
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Orthodontic treatment expectations differ among patients and parents.
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Orthodontic treatment expectations are associated with sociodemographic factors.
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Orthodontic treatment expectations vary among United States and European University centers.
Orthodontic treatment expectations vary depending on the perception of one’s dentofacial appearance. , Esthetics and functional improvement are common reasons for pursuing orthodontic care. Social norms and external influences, such as the parents are also important motivating factors. , Indeed, parents are often more motivated compared to their children regarding orthodontic treatment, and expect orthodontic care to provide occupational and social advantages to their children. Patients’ motivation has a positive correlation with treatment satisfaction, while pain, discomfort, and functional limitations during orthodontic treatment may decrease patient cooperation. It has been reported that only 34% of patients are totally satisfied after orthodontic treatment, and patients with unrealistic expectations are prone to treatment dissatisfaction.
Studies , , with varying methodologies have evaluated orthodontic treatment expectations using questionnaires. Two studies , assessed orthodontic treatment expectations of parents and not the patients, and 2 studies , evaluated orthodontic treatment expectations of patients only. Three studies , , measured participants’ orthodontic treatment expectations after the screening visit or during orthodontic treatment. Other studies , , , have measured both patients’ and parents’ orthodontic treatment expectations at or before the screening visit. A variability has been observed in the results of these studies. , , For instance, Tung et al showed that the participants expected an improvement in self-image and oral function with orthodontic treatment, and no significant changes were anticipated in the child’s general health. Conversely, Bos et al found that most participants expected an improvement in general health with orthodontic treatment. It has also been reported that orthodontic treatment expectations are influenced by sociodemographic factors , and vary among English and Dutch, and Greek and Italian participants.
A systematic review concluded that most questionnaires that have been used to assess orthodontic treatment expectations have poor quality of methodology. A validated questionnaire has been used to assess and compare patients’ and parents’ expectations before orthodontic treatment in University centers in Europe [Academic Centre for Dentistry Amsterdam (ACTA), the Netherlands and King’s College Dental Hospital (KC), London, United Kingdom ]. Moreover, Hiemstra et al compared participants’ orthodontic treatment expectations between ACTA and KC. To the authors’ knowledge, a similar study is yet to be conducted in a University setting in the United States.
With this background, the primary aim of this study was to evaluate and compare patients’ and parents’ orthodontic treatment expectations before orthodontic screening at the University of Rochester (UR) in the United States. Secondary aims were to assess the association between sociodemographic factors and UR participants’ orthodontic treatment expectations and compare participants’ expectations between UR, and KC and ACTA (previously published data , ).
Material and methods
In this observational cross-sectional study, patients and one of their parents were asked to complete a psychometrically validated questionnaire before the screening visit at the Orthodontic Department at UR. If both parents were present at the screening visit, one was randomly selected to participate with a coin flip. The inclusion criteria were as follows: (1) patients aged 10 to 15 years; (2) patients who did not previously undergo orthodontic treatment; (3) no developmental anomalies (such as cleft lip and/or palate), mental or psychological disorders; and (4) participants who could communicate and read in English; (5) provided written informed consent and/or assent; and (6) completed all sections of the questionnaire. Participation in this study was voluntary, and patients, and parents provided written informed assent and consent, respectively. Parents also provided written permission for their child to participate. This study was approved by an Institutional Review Board at UR (RSRB00071034).
The questionnaire used in the present study has been previously tested for validity and reliability, and has been used in different samples. , , , Briefly, the questionnaire was qualitatively developed in a study by Sayers and Newton, and was piloted on a small cohort of patients and their parents to assess readability. A test and retest of the questionnaire on 2 separate occasions demonstrated that the scores provided on these 2 occasions were reliable over time. The questionnaire produced a good level of internal consistency when tested using the Cronbach’s alpha, with an overall interitem value of 0.76; and more than 50% of questions achieved a corrected item-total correlation of >0.3.
The present questionnaire consists of 10 questions: 8 questions (1-7 and 10) use a visual analog scale response code, marked at 10-mm intervals, ranging from 0 (“extremely unlikely”) to 100 (“extremely likely”); and 2 questions (8 and 9) use categorical response codes. The millimeter distance between the mark on the visual analog scale (participant’s response) and left-hand side of the scale (“0”) was measured to assess the scores for questions 1-7 and 10; and questions 8 and 9 had 11 and 10 response options, respectively. This questionnaire measures orthodontic treatment expectations in regard to the initial appointment, type of treatment, expected experiences during orthodontic treatment, treatment duration, frequency of visits, and benefits of orthodontic treatment. Sociodemographic factors (self-reported) such as participants’ age, gender, ethnicity, race, family history of orthodontic treatment, health insurance, parental education and employment status, and annual household income (AHI) were assessed. Racial groups (White, American Indian or Alaska Native, Black or African American, Native Hawaiian or other Pacific Islander, and Asian) and ethnicity categories (Hispanic or Latino and not Hispanic or Latino) were defined on the basis of the Office of Management and Budget’s 1997 revised standards for the classification of data on race and ethnicity. ,
The parents completed the questionnaire in the waiting room, and the patients completed the questionnaire in the clinic. All participants completed the questionnaire under the supervision of the first author (D.M), and before receiving any information regarding orthodontic treatment. After completing the questionnaire, the patients received their orthodontic consultation with a resident at the orthodontic department.
Ten participants were asked to complete the questionnaire twice before the screening visit (1-hour apart) to assess reproducibility in their responses and test the questionnaire in this study’s population. All measurements were conducted by a standardized examiner (S.P). After study completion, the same examiner (S.P) remeasured 16 randomly selected questionnaires to evaluate intraobserver reliability. A second examiner (D.M) remeasured 16 randomly selected questionnaires to assess interobserver reliability.
Data regarding participants’ orthodontic treatment expectations in KC and ACTA were collected from the results of previously published studies , that used a similar study design and same questionnaire, and authors were contacted to retrieve any relevant information that was not reported in the published results.
Statistical analysis
A sample size of 134 subjects [67 patients and one parent each (n = 67)] achieves 80% power to detect a 7-mm difference, with a standard deviation (SD) of 20, between patients’ and parents’ responses (question 3), with significance level set at 0.05.
The paired t test followed by a multiplicity correction as proposed by Benjamini et al (questions 1-7 and 10), and the Fisher exact test (questions 8 and 9) were used to compare the responses between UR patients and parents. Because some of the response options for questions 8 and 9 were not used, they were combined to 6 options, as described previously. ,
The two-sample t test (questions 1-7 and 10) was used to compare UR participants’ responses between sociodemographic factors (men vs women; Hispanics vs non-Hispanics; with vs without family history of orthodontic treatment; parental education level of more than vs equal or less than 12 years; parents who were employed vs unemployed; and with AHI of less than vs equal or more than $35,000). The Pearson correlation coefficient was used to assess the influence of age on participants’ responses. One-way analysis of variance was used to compare the responses (questions 1-7 and 10) of patients and parents among Medicaid, non-Medicaid, and no insurance groups. The Fisher exact test was used to compare the responses to questions 8 and 9 between sociodemographic factors for patients and parents, respectively.
Responses of patients and parents, respectively, were compared between UR, KC, and ACTA using the one-way analysis of variance and the Tukey test (questions 1-7 and 10); and the Fisher exact test (questions 8 and 9). A multiplicity correction as proposed by Benjamini et al was used to control the false discovery rate.
The concordance correlation coefficient was used to assess the intra and interobserver reliabilities, and the reproducibility in the participants’ responses.
Data analysis was implemented using the SAS software (version 9.2; SAS Cary, NC), with significance level set at 0.05.
Results
The reproducibility of participants’ responses, and the intra and interobserver reliabilities were high (concordance correlation coefficient >0.999).
A total of 140 participants [70 patients and one of their parents (n = 70)] completed the questionnaire between May 2018 and April 2019. All participants answered all questions of the questionnaire.
The mean age (±SD) of the patients was 12.49 (±1.49) years; and there was an equal number (n = 35) of men and women. Approximately 25% of the patients (n = 18) were Hispanic; and approximately 75% of the patients (n = 52) were non-Hispanic (total of 70 patients). Regarding patients’ race, 25 patients were African American, 19 were White, 5 were Asian, 1 was American Indian, and 20 patients did not identify themselves of any specific race (total of 70 patients). Twenty-two patients reported a family history of orthodontic treatment (their parents and/or siblings underwent orthodontic treatment in the past).
The mean age (±SD) of the parents was 39.49 (±8.76) years; and there were more female (n = 57) than male (n = 13) parents. Approximately 27% of the parents (n = 19) were Hispanic; and approximately 73% of the parents (n = 51) were non-Hispanic (total of 70 parents). Regarding parents’ race, 24 parents were African American, 23 were White, 7 were Asian, and 16 parents did not report a specific race (total of 70 parents). Twenty-five parents reported previous experience with orthodontic treatment (the parents and/or their child-patient’s siblings underwent orthodontic treatment in the past). Sixty-one parents had health insurance; and approximately 75% (n = 46) of the insured had Medicaid and/or Medicaid products. Forty-six parents had completed more than 12 years of education; and 24 parents had completed equal to or less than 12 years of education. Fifty parents were employed at the time of orthodontic screening. Thirty-six parents reported an AHI of less than $35,000; and 34 parents reported an AHI equal or more than $35,000.
Patients expected less of a check-up and diagnosis (question 1b) ( P = 0.0115), and less discussion about treatment (question 1c) ( P = 0.0069) at the initial visit than parents. Patients expected more dietary restrictions during orthodontic treatment (question 6) than parents ( P = 0.0023). Parents more so than patients, expected orthodontic treatment to produce a better smile (question 10b) ( P = 0.0258) and provide confidence socially (question 10g) ( P = 0.0115) ( Table I ).
| Questions (1-7 and 10) | Patients (n = 70) | Parents (n = 70) | P value ∗ | ||
|---|---|---|---|---|---|
| (M) | (SD) | (M) | (SD) | ||
| 1. At your initial appointment do you expect to: | |||||
| a. Have a brace fitted? | 43.77 | 28.72 | 43.27 | 36.71 | 0.9043 |
| b. Have a check-up and diagnosis? | 63.74 | 29.01 | 79.06 | 24.18 | 0.0115 ∗ |
| c. Have a discussion about treatment? | 70.99 | 24.07 | 83.54 | 22.11 | 0.0069 ∗ |
| d. Have X-rays? | 69.14 | 27.82 | 78.51 | 26.40 | 0.1162 |
| e. Have impressions? | 56.67 | 26.20 | 63.54 | 32.15 | 0.3133 |
| f. Have oral hygiene checked? | 66.61 | 28.56 | 71.64 | 33.23 | 0.4707 |
| 2. What type of orthodontic treatment do you expect? | |||||
| a. Braces, don’t know what type? | 72.60 | 26.07 | 78.17 | 27.26 | 0.4020 |
| b. Train track braces? | 56.91 | 27.71 | 60.57 | 31.11 | 0.5171 |
| c. Teeth extracted? | 26.90 | 25.37 | 31.10 | 32.49 | 0.4605 |
| d. Head brace? | 12.97 | 20.11 | 12.34 | 17.76 | 0.8702 |
| e. Jaw surgery? | 11.33 | 17.86 | 12.01 | 17.80 | 0.8702 |
| 3. Do you think orthodontic treatment will give you any problems? | 26.10 | 27.08 | 23.47 | 24.71 | 0.7714 |
| 4. Do you think wearing braces will be painful? | 48.40 | 30.24 | 40.94 | 24.65 | 0.3016 |
| 5. Do you think orthodontic treatment will produce problems with eating? | 46.20 | 32.14 | 39.87 | 29.45 | 0.4020 |
| 6. Do you expect orthodontic treatment to restrict what you can eat or drink? | 69.57 | 28.02 | 50.36 | 33.16 | 0.0023 ∗ |
| 7. How do you think people will react to you wearing a brace? | 71.34 | 22.68 | 66.81 | 27.12 | 0.3260 |
| 10. Do you expect orthodontic treatment to: | |||||
| a. Straighten your teeth? | 83.87 | 18.90 | 88.81 | 15.84 | 0.2790 |
| b. Produce a better smile? | 80.20 | 23.75 | 89.93 | 14.36 | 0.0258 ∗ |
| c. Make it easier to eat? | 65.10 | 27.84 | 67.43 | 33.60 | 0.7837 |
| d. Make it easier to speak? | 61.24 | 29.29 | 63.34 | 36.08 | 0.7899 |
| e. Make it easier to keep my teeth clean? | 72.37 | 27.78 | 70.33 | 31.37 | 0.7837 |
| f. Improve my chances of a good career? | 62.59 | 30.67 | 70.21 | 34.29 | 0.3160 |
| g. Give you confidence socially? | 72.31 | 29.93 | 86.23 | 21.57 | 0.0115 ∗ |
∗ Paired t test and multiplicity correction (as proposed by Benjamini et al ); statistically significant differences ( P <0.05).
Expectations regarding the duration of orthodontic treatment (question 8) ( Table II ) and frequency of appointments (question 9) ( Table III ) did not differ significantly between patients and parents ( P = 0.12 and P = 0.20, respectively). Twenty patients and 24 parents, and 15 patients and 22 parents had no idea regarding the duration of orthodontic treatment, and frequency of appointments, respectively.
| Treatment duration | Patients, n = 70, (%) | Parents, n = 70, (%) | Total number, n = 140, (%) |
|---|---|---|---|
| <1 year | 12 (∼17) | 3 (∼4) | 15 (∼11) |
| 1-1.5 years | 14 (20) | 9 (∼13) | 23 (∼16) |
| 1.6-2 years | 14 (20) | 21 (30) | 35 (25) |
| >2-3 years | 8 (∼11) | 10 (∼15) | 18 (∼13) |
| >3 years | 2 (∼3) | 3 (∼4) | 5 (∼4) |
| Don’t know | 20 (∼29) | 24 (∼34) | 44 (∼31) |
| Frequency of appointments | Patients, n = 70, (%) | Parents, n = 70, (%) | Total number, n = 140, (%) |
|---|---|---|---|
| <1 month | 6 (∼9) | 1 (∼2) | 7 (5) |
| 1-2 months | 31 (∼44) | 29 (∼42) | 60 (∼43) |
| >2-3 months | 5 (∼7) | 8 (∼11) | 13 (∼9) |
| >3-6 months | 13 (∼19) | 10 (∼14) | 23 (∼17) |
| >6 months | 0 (0) | 0 (0) | 0 (0) |
| Don’t know | 15 (∼21) | 22 (∼31) | 37 (∼26) |
Patients’ age was not significantly correlated with patients’ responses. Parents’ age was positively correlated with parental expectations of having impressions taken at the initial visit (questions 1e) ( P = 0.02) and orthodontic treatment producing problems with eating (question 5) ( P = 0.03).
Male patients, more so than female patients, expected to have impressions taken (question 1e) ( P = 0.01) and oral hygiene checked (question 1f) ( P = 0.04) at the initial visit, and orthodontic treatment to straighten their teeth (question 10a) ( P = 0.04). There were no significant gender differences in parental responses.
Hispanic patients, more so than non-Hispanic patients, expected braces being placed (question 1a) ( P = 0.02) and oral hygiene checked (question 1f) ( P = 0.02) at the initial visit. A greater percentage of Hispanic (50%) than non-Hispanic patients (approximately 21%) had no idea regarding the duration of orthodontic treatment (question 8) ( P = 0.04). There were no significant ethnic differences in parental responses.
Patients with a family history of orthodontic treatment expected more tooth extractions (question 2c) ( P = 0.02) than patients without a family history of orthodontic treatment. Parents who had previous experience with orthodontic treatment expected less braces being placed at the initial visit (question 1a) ( P = 0.007), and more problems with eating during orthodontic treatment (question 5) ( P = 0.03). The percentage of parents that had no idea regarding the duration of orthodontic treatment (question 8) was smaller in parents with (12%) than without (∼ 47%) previous experience with orthodontic treatment ( P = 0.001).
Patients whose parent had more than 12 years of education expected more problems with eating during orthodontic treatment (question 5) ( P = 0.005), and less improvement in mastication with orthodontic treatment (question 10c) ( P = 0.04) than patients whose parent had equal or less than 12 years of education. Parents with more than 12 years of education expected more of a discussion about treatment at the initial visit (question 1c) ( P = 0.02), and that orthodontic treatment would provide confidence socially (question 10 g) ( P = 0.01) than parents with equal or less than 12 years of education.
Patients whose parent was employed expected that orthodontic treatment would have less of an improvement in oral hygiene (question 10e) ( P = 0.02) and social confidence (question 10g) ( P = 0.02) than patients whose parent was unemployed. There were no significant differences in parental responses between employed and unemployed parents.
Patients with an AHI of equal or more than $35,000 expected more problems with eating (question 5) ( P = 0.03) and more dietary restrictions (question 6) ( P = 0.04) during orthodontic treatment than patients with an AHI of less than $35,000. There were no significant differences in responses between parents with an AHI of equal or more compared with less than $35,000.
Responses did not differ significantly between patients with Medicaid, non-Medicaid, and no health insurance, and the same was observed for the parents.
Patients at UR expected more braces being placed (question 1a), less check-up and diagnosis (question 1b), and more of a discussion about treatment (question 1c) at the initial visit than patients at ACTA. Patients at UR expected more to have radiographs taken at the initial visit (question 1d) than patients at ACTA and KC. Patients at UR expected less extractions during orthodontic treatment (question 2c) than patients at KC, and less headgear (question 2d) than patients at ACTA. Patients at UR expected less problems with eating during orthodontic treatment (question 5) than patients at ACTA and expected a more favorable reaction by the public (question 7) than patients at ACTA and KC. Patients at UR expected more improvement in smile esthetics (question 10b), eating ability (question 10c), speech (question 10d), ability to clean the teeth (question 10e), career prospects (question 10f), and social confidence (question 10g) with orthodontic treatment than patients at ACTA and KC ( Table IV ).
