Motivation, Compliance and Satisfaction in Orthodontic Treatment

MOTIVATION, COMPLIANCE AND SATISFACTION IN ORTHODONTICS 99
EXCELLENCE IN ORTHODONTICS 2016
Chapter
8
Motivation, Compliance and
Satisfaction in Orthodontic Treatment
David Birnie
100 MOTIVATION, COMPLIANCE AND SATISFACTION IN ORTHODONTICS
Introduction
While there are many technical aspects within the orthodontist’ control during orthodontic treatment, the success
of treatment is very much a partnership between the orthodontist and the patient (and their parents or carers).
Understanding why patients want orthodontic treatment, what influences their compliance with treatment and
their satisfaction with treatment are important in ensuring high quality treatment is delivered as efficiently as
possible and at the lowest cost to the patient and the provider, reduces the chance of treatment failure and protects
patients and providers from misunderstandings and disputes. In this chapter, motivation will be about why patients
seek orthodontic treatment, compliance will be about how well patients cooperate with treatment and satisfaction
will be about the match between patient’s expectations of treatment and the reality of the result.
Motivation
Why do patients seek orthodontic treatment? Motivation is a reason, or reasons, for acting or behaving in a
particular way; put more scientifically, the biological, emotional, cognitive or social forces that activate and direct
behaviour ie: goal-directed behaviour. Motivation is a psychological drive that compels or reinforces an action
toward a desired goal and may have its origins in a basic response to optimize well-being; minimize physical pain
and maximize pleasure, or originate from specific physical needs such as eating, sleeping or resting, and sexual
reproduction. Motivation maybe internal or external. Internal motivation is motivation that is driven by an interest
or enjoyment in the task itself, and exists within the individual rather than relying on any external pressure or reward
whereas external motivation comes from outside of the individual. Common external motivations are parental
pressure, rewards (financial, grades or marks) and the threat of punishment or disapproval.
The principal factors that determine a patient’s perceived need for treatment are:
• aesthetic
• functional
• financial
• social
The orthodontist uses objective measures of treatment need (indices) to prioritise oral pathology (if present),
function and occlusion. The patient however may feel that other factors are just as or more important (Josefsson et
al 2009).
Wędrychowska-Szulc and Syryńska (2010) carried out a study in Poland on 674 children aged between 7 and 18
years of age. Most patients chose a desire to improve their appearance as the reason for seeking orthodontic
treatment. As age increased, so did dissatisfaction with appearance although this dissatisfaction occurred more
slowly in males than females. The influence of parents, carers or guardians and other advisors, such as the dentist,
on the patient’s decision to undergo orthodontic treatment declined with age. Less than 5% of patients sought
treatment as a result of influence from their peers. Health did not seem to be a key motivational factor in patients
seeking orthodontic treatment. Parents, carers or guardians also rated improved appearance as a reason for the
child having treatment; 64% of parents, carers or guardians reported that they sought treatment for their child out
of fear of any possible future blame from the child that their parents/guardians neglected their duty to make sure
they underwent orthodontic treatment. This study also found that the final decision of parents/guardians for their
child to undergo orthodontic treatment was not solely their own but also influenced by the referring dentists, other
physicians, and speech therapists although this influence decreased significantly with increasing age of the
children.
In 2012, Prabakaran et al investigated motivational factors in children and their parents seeking orthodontic
treatment using Q methodology. Q Methodology is a research method used in psychology and other social sciences
to study people's "subjectivity" or their viewpoint. It has been used both in clinical settings for assessing patients,
as well as in research settings to examine how people think about a topic. The name "Q" comes from the form of
factor analysis that is used to analyse the data. Normal factor analysis, called "R method," involves finding
correlations between variables such as height and age across a sample of subjects. Q however looks for correlations
between subjects across a sample of variables. Q factor analysis reduces the many individual viewpoints of the
subjects down to a few "factors," which represent shared ways of thinking. Adolescent patients between the ages
of 10 and 16 years were included in the study but patients with clefts of the lip or palate, craniofacial syndromes,
and potential orthognathic patients were excluded it was felt that they were not representative of the typical
orthodontic population. Parents accompanying eligible patients at new patient consultations provided the parent
group; these were recruited independently of the patients to avoid confounding influences between the groups.
The study was in two parts. Firstly, patients and parents were interviewed to generate a list of reasons or themes as
to why adolescent patients wanted have orthodontic treatment or why parents wanted their child to undergo
treatment. Once no new themes emerged and saturation had been reached, the interviewing process stopped.
This generated 32 items from the patients and 35 items form the parents; the items were listed on individual cards
for placement in two separate Q-methodology grid. The methodology for ranking the statements is described in
the paper. Generally, the patients sought treatment because they wanted to improve the alignment of their teeth
and were dissatisfied with their dental appearance. The 22 boys were motivated to seek treatment because they
wanted to improve the alignment of their teeth and because they thought that treatment was necessary while the
38 girls wanted to enhance their dental alignment and viewed their current dental appearance as unsatisfactory.
For the parents, there was little difference between the mothers’ and fathers’ responses, so the results were pooled.
The statement that received the highest average score was “future problems might be caused if my child does not
get treatment,” and the second statement also recognized the importance of treatment timing. Of the remaining
statements in the “most important” zone, two described the need for treatment, and three described aesthetics. In
the analysis of the factors for patients, the highest number of patients mapped to a factor called aesthetics and social
acceptance in which most of the statements related to aesthetics, although some related to improving social image.
Factor two was aesthetics and perceived need which included statements related to practical needs; however, there
were also concerns regarding aesthetics and opinions of family members. Factor three statements related primarily
to aesthetics and self-esteem.
For the parents, factor one was avoidance of future problems and managing difficulties and the most important
statements focussed on the avoidance of future problems by having treatment in adolescence and the awareness
that their child was experiencing difficulties in some aspects of day-to-day life. Factor two was aesthetics, need, and
timing and parents had a high awareness of the importance of the timing of treatment, but more importance was
placed on aesthetics and also on the child’s and the general dentist’s awareness of treatment need. Factor three
was dentist/parental influence and perceived need and these parents ranked the general dentist’s, and their own,
awareness of need as the two most important reasons for orthodontic treatment, but the desire to avoid future
problems by treating now was deemed the next most important area. Factor four was parental concern for child’s
well-being and the most important statements focused on making the child happy and ensuring that they did the
best for their children. Aesthetics was also an important element in this factor.
Key point: Aesthetics is a major motivating factor for adolescent patients seeking orthodontic
treatment. However, parents do not rate
aesthetics as important as the need to prevent
future problems by treating during adolescence.
Motivation in children and adolescents

Shaw (1981) summarised a basic hypothesis about
motivation in children by suggesting that the severity
of any visible dental irregularity was an important
determinant of a child’s level of satisfaction with his
dental appearance, his perceived need for
orthodontic treatment and promised compliance
with treatment if a course of treatment were
recommended by a dentist (Figure 8.1). It was also
Figure 8.1 : The hypothesised relationship between severity of
hypothesised that the individual’s judgement would
dental irregularity and satisfaction with dental appearance, perceived need
be influenced by other characteristics such as sex, for treatment and compliance (Shaw 1981)
intelligence and experience of teasing. Note that compliance in this study was measured as willingness to wear a
brace if asked to by the dentist. The study concluded that the degree of visible occlusal irregularity was an important
determinant of satisfaction with dental appearance and the wish to have orthodontic treatment. However, some
children with severe irregularity were satisfied with their dental appearance while others with mild irregularity were
not. This was attributed to three possible causes:
• variation in the range of malocclusion considered acceptable by the children in the study
• other characteristics of the child which influenced feelings about dental appearance and the desire
for treatment. These might include:
o the adoption of sex-role stereotypes with girls considering themselves of below average
attractiveness, admitting to more frequent mirror viewings and more than twice as many girls as
boys being dissatisfied with their dental appearance. In this study, the children’s age ranged
between nine and twelve years but even in this narrow range, the satisfaction in dental
appearance decreased with increasing age. Teasing was reported more frequently in children
with severe irregularity and there was an association between teasing and the wish to have
orthodontic treatment. Finally, satisfaction with dental appearance and the perceived need for
treatment were unrelated to social class and intelligence although irregular dental attenders
reported higher levels of dissatisfaction with dental appearance
• the third possible reason for inconsistencies between objective and subjective acceptability of dental
features is inaccuracy in the child's (and parents') perception of the actual dental arrangement. The
study revealed significant levels of description and identification accuracy in children and their
parents when asked to either describe the problems with their teeth or to identify their teeth from
photographs. This highlights the role of the dentist or orthodontist in helping patients to make
informed decisions about treatment need and the benefits of treatment
In 1992, Espeland et al carried out a similar study to that of Shaw (1981) but on nine to eleven year old Norwegian
children. The authors found that there was no difference between the responses of Welsh and Norwegian patients
and their parents; only about 50% of the Norwegian children and parents identified the correct photograph at the
first attempt. Also in a study in 1992, Espeland et al related the rankings in a Norwegian index of orthodontic
treatment need to the concerns of 11 year old children and their parents. Approximately half of the children and
parents of children in the ‘great need’ group and two thirds of those in the ‘obvious need’ group did not report
concern (the groups were called very great, great, obvious and little/no need).
What becomes clear from these and other studies is that 10-12-year-old children often do not accurately identify
their malocclusion and are therefore often unable to make decisions on aesthetic improvement.
90 Motivation for patients to have

80
orthognathic surgery
70 Patients having orthognathic surgery have
60 different reasons for seeking treatment. Nurminen
50 et al (1999) asked 28 patients having orthognathic
%
40 surgery why they were seeking professional help.

30 68% of the patients reported that it was because of
20
eating problems, 36% because of facial
appearance, 32% because of temporomandibular
10
joint dysfunction, 32% because of ‘symptoms from
0
Children Parents Children Parents Young adults
head’ and 36% for some other reason.
(Wales) (Wales) (Norway) (Norway) (Norway)
Some studies put improvement in facial
Identified photo Unable to identify photo
appearance above improvement in function
Figure 8.2: Only about 50% of children and their parents (Athanasiou et al 1989, Williams et al 2005). Proothi
identified photographs of their children’s teeth correctly the first time. et al (2010) looked at just over 500 questionnaires
However, by adulthood, the success in photographic identification had of patients who had decided to have orthognathic
increased significantly.
surgery and found that 76% felt that their appearance was affected by their condition but only 15% said that it was
their prime motivation for surgery. However, 36% felt that their bite was the prime motivation for surgery.
Key point: Functional reasons rate much more highly as a reason for seeking treatment for patients
undergoing orthognathic surgery than for orthodontics only. Studies are however equivocal on which
reason is more important.
Type of appliance
Bergström et al (1998) in their study on 27-year-old Swedish adults divided their sample in to four groups:
• treatment with appliances

• treatment without appliances
• no treatment but had a treatment need
• no treatment and no treatment need
When asked the questions ‘Did you or would you have been able to wear visible braces during adolescence if needed?’,
84% answered ‘Yes, definitely’ or ‘Yes, probably’. There were no statistically significant differences between the four
groups but for the two groups treated with appliances, 67% of those treated by specialists answered that they would
have felt able to accept visible appliances compared with 32% of those treated by general dental practitioners.
When asked the question ‘Would you have been able to wear visible braces as an adult if needed?, 67% responded ‘Yes,
definitely’ or ‘Yes, probably’. The percentage for treated individuals was 60% compared with 77% for untreated
individuals. This suggests that between 16% of adolescents and 33% of young adults are put off wearing braces
because of their appearance.
In 2008, Ziuchkovski et al investigated the aesthetics of orthodontic appliances by asking adults to rate standardised
digital photographs of different appliances in the mouth using a visual analogue scale. The photographs had been
modified using Adobe Photoshop to ensure that factors such as tooth exposure, tooth shape and colour and lip
drape remained constant. The study included type of appliance (aligners - simulated by using clear vacuum formed
trays, and lingual appliances, ceramic brackets, stainless steel and hybrid self-ligating brackets and stainless steel
twin brackets), wire type (standard and aesthetic ‘coated’ wires) and ligature type (wire ties and clear elastomeric
ties). The authors pooled aligners and lingual appliances under the term ‘alternative appliances’. The study found
that:
• the hierarchy of attractiveness of orthodontic appliances was alternative appliances > ceramic
brackets > stainless steel self-ligating and standard twin brackets
• the attractiveness of orthodontic appliances did not differ significantly between brands for the same
type of appliance
• orthodontic appliance attractiveness can vary between wire and ligature selection in ceramic bracket
appliances but as inconsistent. Wire selection had no effectiveness on the attractiveness of stainless
steel or self-ligating brackets
This study introduced the concept of critical metal appearance where once a certain level of metal is visible, the
addition of more has little effect on perceived appearance. For example, wire ties added to a ceramic bracket with
an aesthetic archwire are perceived as decreasing the attractiveness of the appliance but not where a metal archwire
was used.
In 2009, Ziuchkovski’s research was extended in another study by Rosvall et al to include the In-Ovation C bracket
and also a willingness to pay value (WTP) for a more aesthetic appliance compared with a standard metal appliance.
Fifty adults undertook the rating exercise. The hierarchy of attractiveness of orthodontic appliances changed to
alternative appliances > ceramic brackets > ceramic self-ligating appliance > stainless steel self-ligating and
standard twin brackets. Appliances such as lingual appliances or aligners were acceptable to cover 90% of adults
whereas commonly used appliances such as stainless steel standard twins were acceptable to only 55% of adults.
The raters were asked about the acceptability of appliances both to themselves and to their children and no
difference was found either in acceptability or WTP values between adults and children. The WTP value was
determined by showing the rater an image (picture A) a standard orthodontic appliance and one of similar size with
another orthodontic appliance (picture B). The rater received these instructions: ’Assume that orthodontic treatment
with the braces shown in picture A will require 24 months of treatment to straighten your teeth and cost $4,500; assume
the braces in picture B are more expensive than those in picture A. How much more money would you be willing to pay
for them to be placed on your teeth?’ The raters could select a financial value between $0 and $1,500. The WTP value
tracked the hierarchy of appliance attractiveness and ranged from $629 for a lingual appliance or aligner to $67 for
a D3 hybrid appliance.
Note that for Ziuchkovski’s and Rosvall’s research, appliance acceptability decreased with increasing metal show
and that all judgements were made by adults either on their own behalf or on behalf of their children.
Walton et al (2010) studied the acceptability of orthodontic appliances to children and adolescents dived into three
age groups (9-11 years, 12-14 years and 15-17 years) using the same methodology developed by Ziuchkovski. They
also changed the list of appliances including WildSmiles star and heart-shaped brackets, using only metal archwires
but adding coloured elastomeric ties; in addition, aged elastomeric ties were simulated. The paper concluded that:
• children and adults differ in their preferences for orthodontic appliances. Reducing metal show in
appliances is not the driving factor for aesthetics among most children and adolescents.
• children’s preferences for orthodontic appliances differ by age and sex. Older children tended to
have a stronger preference for clear appliances than younger children. Shaped brackets were
preferred most by younger patients and girls.
• stainless steel brackets with coloured ties and clear tray aligners were highly accepted by all age
groups.
• coloured elastomeric ties contribute significantly to the attractiveness of orthodontic appliances for
children and adolescents. Over 85% of patients found this type of appliance acceptable
While many orthodontists now use self-ligating brackets, these proposed advantages seem to come at a cost to
patient aesthetics. Among children aged 9 to 14 years of age, all self-ligating systems were considered significantly
less attractive than traditional twin brackets with coloured elastomeric ties. Furthermore, in all age groups,
acceptability rates for any self-ligating bracket were 23% to 46% lower than traditional twin brackets with coloured
elastomeric ties.
Jeremiah et al (2011) studied the influence of the appearance of orthodontic appliances on subject’s perception on
intellectual ability, social competence, psychological adjustment and attractiveness. The study used modified
digital images to portray no appliance, a stainless steel fixed appliance, a gold fixed appliance, a fixed appliance
using ceramic brackets and a clear aligner. A ten question structured questionnaire was used to determine the
raters feelings about intellectual ability, social competence, psychological adjustment and attractiveness based on
physical appearance using Likert (usually five point) scales. The results showed that greater perceived intellectual
ability was associated with the appearance of no appliance, gold and aligner appliances compared with steel or
ceramic appliances. No significant differences were found for social competence or psychological adjustment
between the different orthodontic appliance appearances. No appliance image (resembling a lingual appliance) or
a clear aligner was considered more attractive than the visible buccal fixed appliances. The study concluded that in
the absence of other information, the judgements an individual young adult makes concerning the personal
characteristics of another young adult are influenced by dental appearance and orthodontic appliance design
which may in turn affect orthodontic appliance choice.
Compliance
At the start of the chapter, it was suggested that compliance was how well patients cooperate with treatment. In
2000, Sergl and Zentner published an article which reviewed current knowledge of patient cooperation during
orthodontic treatment. In a much earlier study (Sergl et al 1973) had revealed that 39% of orthodontists predicted
a patient’s compliance on the basis of a general impression of behaviour, receptiveness and intelligence, 6% on
their impression of the parents, 25% considered the child’s interest, 33% considered the parents’ interest in
orthodontics and 12% used the level of oral hygiene to predict future cooperation. Rather than subjective
assessment, it was thought better if simple, systematic objective methods of assessing patient compliance could be
developed.
Demography
Age has been suggested as a predictor of compliance and moreover that higher levels of compliance may be
expected from patients aged 12 years and younger compared with adolescent patients. Other studies have shown
no relationship between patient’s age and compliance; in fact, age is probably a proxy for psychological maturation.
Some adolescents will develop healthy living habits and show significant responsibility for themselves while others
will develop behaviour patterns that put their health at risk and which show little responsibility for their contribution
to their own health.
Patient’s gender is also an unreliable predictor of compliance. While girls express lower body image satisfaction
and are more likely to be unhappy with their dental appearance compared with boys and these characteristics may
strengthen their wish to seek and accept orthodontic treatment, these very characteristics may make girls less
willing to wear highly visible appliance and so may reduce compliance. Neither age nor gender are considered
reliable predictors of compliance with orthodontic treatment.
Studies that have looked at the patient’s socioeconomic status have delivered mixed messages. Better compliance
has been attributed to patients from higher, middle and lower socioeconomic groups with various theories to
support the findings. There is no evidence to support parental occupation as a discriminator or whether the
treatment is paid for privately rather than by a third party.
Finding a single reliable compliance predictor from a patients' demographic characteristics is too simplistic and is
therefore not possible. Nevertheless, knowledge of a patient's socioeconomic and cultural background may provide
helpful supporting information about a patient’s likely compliance with orthodontic treatment.
Psychosocial and psychological factors

The characteristics of a patient’s personality such as their relationship with their parents, their peers, the
orthodontist and their performance at school are all thought to be helpful indicators of compliance. Compliant
orthodontic patients tend to do better at school, are well-behaved, are thought to be academically brighter and
more sociable by their teachers and have higher levels of self-perceived cognitive competence.
Although the parent-child relationship or the parents’ attitude to orthodontic treatment may be thought to be
significant factors in predicting compliance, the patient’s personal psychological characteristics may be more
powerful influencers of compliance with orthodontic treatment. However, parents may play a significant role in a
child’s decision to seek orthodontic treatment and may influence a child’s compliance in the early stages of
treatment.
In 1992, Nanda and Kierl carried out a prospective study of patient cooperation in orthodontics by exploring the
contribution of the following variables to orthodontic compliance.
• parent-child relationship
• psychosocial characteristics of the parent(s).
• psychosocial characteristics of the child
• child's attitude and opinions about orthodontics
• parent's attitude and opinions about orthodontics
• parent's perception of the degree to which the child is compromised socially
• child's perception of the degree to which he/she is compromised socially
• parent(s)/patient's relationship to the orthodontist
• demographics of the parent(s) and the child
The authors concluded that because of the complex nature of and subjectivity in the design of the measuring
instruments, as well as responses to the questionnaires, it was difficult to predict patient cooperation. The
outstanding feature of this investigation was that the orthodontist-patient relationship had a positive impact on
the cooperative behaviour of the patient.
In a study comparing very cooperative patients with very uncooperative patients, it was found that irrespective of
gender, the patients who tend to be uncooperative had attitudinal preferences conventionally regarded as
masculine eg: active, aggressive, realistic behavioural patterns and self-images whereas cooperative patients were
sensitive and had aesthetic and idealistic behaviours. Impulsiveness, need for ego-assertion, individualism,
impatience, intolerance, and negligence are also characteristic psychological traits of the non-cooperative patient.
Patients more likely to show higher levels of treatment compliance are enthusiastic, outgoing, energetic, self-
controlled, responsible, trusting and diligent.
Monitoring compliance with removable appliances

Microsensors, such as Theramon and SmartRetainer, are now available to help monitor how much removable
appliances are being worn. Both types of microsensor are embedded in the appliance and then subsequently read
by a reading device with which the microsensors connect wirelessly. In a study by Tsomos et al in 2013, the times
removable appliances were worn for were monitored in 45 patients using the Theramon microsensor and variables
such as prescribed wearing time, age and sex were recorded. The Theramon microsensor monitors surrounding
temperature every 15 minutes and then transmits the stored data to a reading station using passive RFID (Radio
Frequency Identification) technology. The prescribed wearing times were 14 hours per day (active appliances) and
8 hours per day (retainers). Patients and their parents were told about the presence of the microsensor and could
refuse to have it fitted; reasons for refusing to have the microsensor embedded in an appliance included
• I can trust my child 100%

• I don’t like to subject my child to ‘big brother is watching you’
• cost
The mean wear time over 186 days was 9.0 hours per day and did not differ between the two groups who were
prescribed different wearing times (14 hours per day and 8 hours per day). Eight patients wore their appliances less
than two hours per day and six did not wear their appliances at all. Age affected compliance negatively (increasing
age resulted in decreased compliance); sex did not affect compliance significantly. Compliance was felt to be
adequate for retainer wear but not for the wear of functional appliances.
A further paper on Theramon was published in 2014 by Schott and Ludwig with 281 participants. The authors found
that although patients were asked to wear their appliances for 12 to 15 hours per day, they did in fact only wear
then for a median of nine hours. Wear was irregular and fluctuating and included many zero hours’ wear days; the
authors showed that for some patients, it was possible to improve their wear behaviour by remotivating the patient
when poor wear patterns were observed.
The SmartRetainer system is described by Ackerman et al (2009).
A brief laboratory comparison of the Theramon and SmartRetainer microsensors is given by Schott and Göz (2010).
Health-related behaviours
Health related behaviours are behaviours are those that reduce behaviours that have a negative effect on health
and increase those that have a positive effect on health. These behaviours may be influenced by the patients'
attitude toward dental aesthetics, the perceived severity of the malocclusion, the desire for orthodontic correction
and the expectations from orthodontic treatment and the patient’s belief in their ability to achieve a successful
result through their own efforts. Treatment compliance seems to be strongly related to the perceived severity of
malocclusion by the patient and the degree to which patients attribute treatment outcomes to their personal efforts
without relying on chance or the efforts of others.
Mehra et al (1996) suggested ten important predictors of compliance which were:
• the patient’s wish for orthodontics

• the frequency of broken appliances
• maintaining good oral health
• interaction between the patient and the orthodontist
• the relationship between the patient and their parents
• the patient’s perception of their malocclusion
• the patient’s perception of their malocclusion
• attendance at appointments
• the patient’s perception of their facial appearance
• parental interest in the patient’s orthodontic treatment
• the relationship between the parents and the orthodontist
Note that seven of these factors relate to the patient and only three to the parents. It also highlights that good oral
hygiene and the response to oral hygiene instruction are helpful supporting information in assessing compliance.
Mandall et al (2007) evaluated the association between completion of orthodontic treatment and quality of life
measures such as age, gender, socio-economic status, type of appliance and need for orthodontic treatment also
evaluated whether compliance with orthodontic treatment (missed appointments and appliance breakages) was
associated with age, gender, socio-economic status, or type of appliance. The data collected included demographic
data, IOTN, a quality if life utility score, a quality of life measure called OASIS (Oral Aesthetic Subjective Impact Score)
and measurements of compliance and whether or not treatment was completed. The authors found that
demographic data was not useful in predicting whether or not a patient would complete treatment and nor did
IOTN or the type of appliance used. Quality of life measures (utility values, OASIS) also did not predict which patients
would complete treatment.
Sinha et al (1996) examined the effects of patient-perceived orthodontist behaviours on the patient perceived
orthodontist-patient relationship, patient satisfaction, and orthodontist-evaluated patient compliance in
orthodontic treatment. The authors used an orthodontist behaviour questionnaire, an orthodontist visit satisfaction
scale, a measure of the patient-orthodontist relationship and an orthodontic patient cooperation questionnaire
originally described by Slakter et al (1980). Patients generally thought that the orthodontist-patient interaction
should be comfortable and warm with an orthodontist who is technically competent and provides adequate
information about the problem and procedures they will perform. If these expectations are not met, then patients
feel disappointed, less satisfied, fail to keep appointments, and do not comply with prescribed instructions. Sinha
et al examined 24 orthodontist behaviours and found nine that were positively correlated with patient compliance
and one that was negatively correlated. In approximate descending order of positive correlation, these were the
orthodontist:
• being polite to patient during the visit

• being friendly to patient
• warning patient when felt procedure might hurt
• carrying on casual conversation and small talk
• making patient feel welcome
• having a calm manner
• working quickly but not rushing
• asking during treatment if patient was having any discomfort
• paying attention to what the patient said
If the orthodontist criticised patient’s teeth or how they had been looking after them, then this was negatively
correlated with patient compliance.
A modification of Slakter’s questionnaire was described by Tervonen et al in 2011. This study was designed to
develop a measure for orthodontists, regardless of type of practice, to assess their opinions about patient
compliance. Statistically significant differences were found between male and female orthodontists as well as
between private and public practitioners in responses to items. 72% of female orthodontists considered that
distorted wires and loose bands described a noncompliant patient very well compared with only 46% of male
orthodontists. Orthodontists working in a publicly funded service had more experience (98%) of patients not asking
about treatment procedures and not answering when asked a question, and also more experience of those patients
(98%) with behaviour indicating that orthodontic appointments were an inconvenience, or treatment procedures
were painful, compared with orthodontists in private practice (89% and 91%). Five factors were extracted from the
principal component analysis. These factors were indifference, or a lack of interest in treatment and appointments;
hostility, which was a hostile attitude toward treatment and appliances; poor oral hygiene, neglect, which was
defined as a failure to wear appliances and non-use, which meant indifference to appointments. The first two factors
explained over half of the common variance of the total scale.
In 2011, Al-Jewair et al investigated the compliance of adolescents receiving two-arch multibracket fixed appliances
with oral hygiene instructions. Plaque index and gingival index were measured when the appliances were fitted,
after one month of treatment and after five months of treatment and 88% of the patients came from middle and
low income families; at five months 73% of patients were judged to be compliant with oral hygiene instructions.
Perceived severity of malocclusion, school performance and living with married parents were found to be significant
predictors of compliance with oral hygiene instructions.
Changing health behaviour

Changing health behaviour is difficult as anyone who has ever made a New Year’s resolution related to their health
will know. However, although changes in behaviour happen naturally and without contact with healthcare
professionals, intrinsic motivation is an important component of such a change and the change occurs when the
patient is ready to make a change. Giving advice is often used to generate changes in health behaviours but when
a patient is pressured to adopt a certain view or action, their natural reaction is to argue for the opposite! However,
the conversational environment in which the advice is given has a significant effect on how the advice is received
and this links with the fact that interpersonal interaction is the most important factor in influencing motivation and
behaviour change. Ambivalence is a normal part of the change process; recognising ambivalence and helping
support the patient through this is an important component of behaviour change. Several theories of health
behaviour change exist and all have their strengths and weaknesses. Prochaska and Di Clemente (1983) described
five stages that people go through when changing their health behaviour; people may cycle between changes or
stop at one stage for a considerable period of time. These are:
• precontemplation (not ready to change)

• contemplation (thinking of changing)
• preparation (ready to change)
• action (making change)
• maintenance (sustaining change)
A sixth stage, relapse, has been added by some commentators and this is where patients revert to their previous
behaviours. This model is known as the trans-theoretical model of behaviour change; it is not the only model but is
one that has been frequently used in healthcare applications.
It has already become apparent in this chapter that the relationship between the patient and the orthodontist is an
important component in encouraging patients to cooperate with treatment. Rollnick et al (2007) describe a three
style model for understanding how healthcare professionals communicate with patients.
• directing the traditionally dominant approach in healthcare where the clinician delivers
expert advice. This requires a good rapport between the clinician and the patient
• following listening and used when a patient is upset or concerned. The objective is not to
solve the problem immediately but to provide help and support
• guiding a more complex style in which the patient and clinician work together to help the
patient identify their own goals and how best to achieve them. This style is used to effect health
behaviour changes particularly in patients who are ambivalent about changing
Four main communication style are used in a guiding style of communication with patients. These are summarised
by the acronym OARS:
• O open questions: open questions reveal unexpected information, allow the patient
to put their perspective across, provide insight into the factors affecting change and helps the
clinician understand the patient’s behaviour
• A affirmations: these how approval of the patient’s efforts and reinforce positive
actions. It also helps the patient believe that they can change
• R reflective listening: this allows the listener to check understanding of what has been
said, and enables the speaker to feel understood thus increasing the rapport between patient and
orthodontist. Reflections can be either short summaries of what the patient has said or a deeper
focus on the meaning of what the patient has said
• S summarising: shows that the clinician has understood and taken note of what
the patient has said, maintains the relationship between the patient and the orthodontist and
ensures no important issues have been forgotten
Motivational interviewing
Motivational interviewing is a style of counselling patients that developed from work with people with addictions.
Motivational interviewing focuses on non-confrontational, empathetic counselling with a strong bond between
clinician and patient, emphasises the perspective of the patient in understanding the challenges of health
behaviour change. Motivational interviewing consists of three elements:
• collaboration the clinician and the patient work together

• evocation the clinician emphasises eliciting the motivation from ‘within’ the patient
• autonomy the clinician gives the patient the freedom to make their own choices
In implementing motivational interviewing, there are four key principles:
• empathy demonstrating empathy reduces the patient’s natural urge to self-defend

• develop discrepancy establish a gap between the patient’s current behaviour and where they
want to be
• roll with resistance avoid arguing! This tends to increase resistance to change
• support self-efficacy build the patient’s confidence and create optimism for change
The importance ruler

A patient’s motivation for change can be assessed using a visual analogue scale from 0 (not important to make a
change) to 10 (extremely important to make a change). Most patients will score somewhere between 3 and 8; it is
important not to ask why the patient has not put a 10 as this produce the opposite of change talk – the reasons why
it is not extremely important to change. Try instead saying “Well, you scored a four so it is at least a bit important to
you, what makes it a bit important to you?” This then releases the motivation the patient does have.
Brief interventions in promoting changes in healthcare behaviour

Time pressures often mean that clinical time is less freely available than we would wish. Short interventions can
incremental build changes in healthcare behaviour. The interventions should focus on assessing motives for
change, raising awareness and supporting change. The importance ruler is a readiness scale; another type of
readiness scale is to ask how confident a patient is about making a change; in this case, asking why the patient put
the score they did reveals the strengths for making a change and asking why they did not score 10, the barriers to
change. Asking permission to discuss the health behaviour issues, demonstrating empathy and linking to clinical
findings help build rapport and motivation with the patient. Supporting the patient to make change is achieved by
encouraging the patient to solve their own problems by finding solutions which suit them, offering strategies or
options to support change and having a plan for change.
For a more detailed discussion of motivational interviewing in dentistry, see Health Behaviour Change in Dental
Practice by Ramseier and Suvan.
Satisfaction with orthodontic treatment

In 1998, Bergström et al looked at how 27 year old patients perceived their malocclusion and how they felt about
treatment they had received as a child. The authors found that most patients were satisfied with their original
treatment decision whether or not they actually had treatment. Dental professionals were felt to have had the
greatest influence on the patient’s decision whether to have treatment or not; females felt that they had received
appropriate information about treatment more than males. Patients treated by specialists had higher levels of
satisfaction than patients treated by general practitioners. Individuals with malocclusion who had refused
treatment were more dissatisfied with their dental appearance and a majority regretted their decision not to have
treatment.
Bos et al (2005) investigated whether there was a relationship between compliance during treatment and
satisfaction with treatment. The authors reviewed 100 patients who had completed orthodontic treatment during
2000 at ACTA (Academic Centre of Dentistry Amsterdam); the patients’ health records were scrutinised to assess
compliance with oral hygiene and the wearing of appliances. In addition, patients were sent a questionnaire which
was divided into six principal areas:
• orthodontist-patient relationship
• situational aspects
• dentofacial improvement
• psychological improvement
• dental function
• residual factors
Compliance was not found to be a predictor of patient satisfaction with treatment and patients who had not been
judged compliant by their orthodontist were not necessarily dissatisfied with the treatment process or outcome.
The most important factor relating to satisfaction with treatment was the patient-orthodontist relationship.
Females tended to be more satisfied with both the patient-orthodontist relationship and the situational aspects of
treatment.
Interestingly, this study was repeated by Keles and Bos in 2012 on patients who completed treatment during 2008
and 2009 at ACTA. The study sample was 115 patients. This study showed that the satisfaction of patients with
orthodontic treatment had significantly increased compared with the study done in 2000. No correlation was found
between gender and patient satisfaction and the patient-orthodontist relationship still seems to be the most
important factor in patient satisfaction. Orthodontists should be aware that a good relationship with the patient
may be even more important for the patient than just a technical successful treatment alone.
In 2006, Al-Omiri and Alhaija, from the Jordan School of Science and Technology (JUST), studied the possible effects
of patient sex, age, extraction therapy, severity of orthodontic problem, and personality traits on their satisfaction
with orthodontic treatment. The study used the Dental Impact on Daily Living (DIDL) questionnaire on 50 patients
for assessment of satisfaction with orthodontic treatment and the NEO Five Factor Inventory (NEO-FFI)
questionnaire for assessment of patient's personality. The NEO-FFI assesses neuroticism, extroversion, openness,
agreeableness, and conscientiousness. The DIDL questionnaire showed that 34% were totally satisfied with their
teeth 62% were relatively satisfied and 4% of the patients were dissatisfied with their teeth after orthodontic
treatment. Age, sex, and pre-treatment orthodontic treatment need had no relationship with the patient's
satisfaction. In this study, dissatisfied subjects scored average or high on neuroticism suggesting that greater care
should be taken in supporting this type of patient through orthodontic treatment.
Trovik et al (2012) investigated the perceptions of possible improvement 10 to 14 years after orthognathic surgery,
and assessed the factors that affected treatment satisfaction. The most frequently reported reason for seeking
treatment was to improve mastication and this feature showed the greatest improvement during treatment. The
second most common reason for seeking treatment was to improve appearance. Equal proportions of participants
reported pain during the orthodontic treatment and surgery (25%; 9 of 36), and 9 persons (25%) still experienced
numbness in the lip 10 to 14 years after treatment. “Very satisfied” with the treatment was reported by 36% (13 of
36) of the responders; 53% (19 of 36) were “reasonably satisfied,” and 8% (3 of 36) were not satisfied. Whether
friends and family noticed a change in the participant’s appearance after treatment was a significant factor affecting
both treatment satisfaction and reporting a good quality of life. The impact from self-reported oral health on quality
of life assessed using Oral Impacts on Daily Performances (OIDP) was still high 10 to 14 years after treatment.
Social media and apps

What is an app?
App is a common term for an application (or program), especially for simple applications that can be downloaded
inexpensively or even for free. Originally optimised for mobile devices such as smartphones and tablets, programs
for laptop and desktop computers are now often referred to as ‘apps’.
Do apps and social media make a difference?

Li et al (2015) from Chengdu in China the effect of using a messaging app, WeChat, on patient compliance and
duration of treatment in a non-blinded randomised controlled trial. The primary outcome measure was duration of
treatment (DoT) and patient attendance, oral hygiene and breakages were also measured. The experimental group
had access to a research WeChat account and the control group had conventional care only. Two types of messages
were provided: appointment reminders in the week before the appointment and educational messages oral
hygiene, what to eat, bracket debonding and orthodontic pain. The control group received the same orthodontic
strategy and educational messages without the use of the WeChat messaging service.
DoT for the WeChat group was significantly shorter (median 80.5 weeks vs 84.5 weeks, mean 7.3 weeks shorter).
The total failed and late attendance were respectively 3.1% and 20.1% for the WeChat group and 10.9% and 29.9%
for the control group. There was no significant difference in the number of patients who had at least on bracket
debonded (56.2% vs 68.8%) but in the adult subgroup, there was a significant difference in favour of the WeChat
group. There was no difference in plaque index or gingival index in either group at the start or end of treatment. In
summary, this paper showed that the use of a social media app could reduce DoT by a mean of 7.3 weeks and the
likely cause of this was reduction in failed appointments. It also improved the rate of bond failure in the adult
subgroup.
18
16
number of white spots
14
12
10
8
6
4
2
0
T0 T1 T2 T3 T4
Control Experimental
Zotti et al (2016) looked at the use of an app to Figure 8.3: The number of white spot lesions in the control and
improve oral hygiene compliance in adolescent experimental groups (Zotti et al 2016)
orthodontic patients. This was a case-control study
in which orthodontic patients were randomly
assigned to the experimental or the control group with 40 patients in each arm. The experimental patients
downloaded smartphone-specific video tutorials regarding oral hygiene maintenance during their orthodontic
treatment, and the patients and their parents to share self-photographs (selfies) and text messages in a WhatsApp-
based anonymous chat room. The experimental patients used a fictional nickname and were not allowed to reveal
their real identity to other participants. This chat room was named “Brush Game” and all participants were
instructed to share two selfies of their teeth weekly, before and after using the plaque-disclosing tablets, to show
their ability in maintaining oral hygiene. The patients were also allowed to use this chat room to share information,
pictures, and movies regarding oral hygiene and orthodontic treatment. Each Saturday, the moderator, after visual
evaluation of the patients' photographs and level of participation in the chat room, published a ranking of the five
best participants of the week.
All patients were examined at baseline and every three months for the first year (to, T1, T2, T3 and T4) and the plaque
index, gingival index, white spots and caries were recorded. At T0, there was no difference in the plaque or gingival
index and the number of white spot lesions between the groups. At T2, T3 and T4, the experimental groups plaque
and gingival indices progressively and significantly improved; the number of white spots improved significantly
only at T3 and T4 as shown in Figure 8.3.
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Motivation, Compliance and Satisfaction in Orthodontic Treatment

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MOTIVATION, COMPLIANCE AND SATISFACTION IN ORTHODONTICS 99

EXCELLENCE IN ORTHODONTICS 2016

Motivation in children and adolescents

90 Motivation for patients to have

40 surgery why they were seeking professional help.

• treatment with appliances

Psychosocial and psychological factors

Monitoring compliance with removable appliances

• I can trust my child 100%

The SmartRetainer system is described by Ackerman et al (2009).

Mehra et al (1996) suggested ten important predictors of compliance which were:

• the patient’s wish for orthodontics

• being polite to patient during the visit

Changing health behaviour

• precontemplation (not ready to change)

• collaboration the clinician and the patient work together

In implementing motivational interviewing, there are four key principles:

• empathy demonstrating empathy reduces the patient’s natural urge to self-defend

The importance ruler

Brief interventions in promoting changes in healthcare behaviour

Satisfaction with orthodontic treatment

Social media and apps

Do apps and social media make a difference?

Bergström K, A Halling A, and B Wilde B (1998)

Josefsson E, Bjerklin K and Lindsten R (2009)

Sinha PK, Nanda RS and McNeil DW (1996)

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