INDIAN DENTAL ACADEMY
Leader in continuing dental education
www.indiandentalacademy.com

www.indiandentalacademy.com
BEHAVIOUR CONSIDERATION
DURING ORTHODONTIC TREATMENT

www.indiandentalacademy.com
INTRODUCTION
THEORIES OF PATIENT BEHAVIOUR
PRATICAL IMPLICATIONS OF THEORIES
DENTAL-FACIAL APPEARANCE AND SOCIAL BEHAVIOUR...
INTRODUCTION
Behavioral dentistry is an interdisciplinary science, which
needs to be learned, practiced and reinforced in ...
Definition:
Behavior is an observable act. It is defined as any change
observed in the functioning of an organism. Learnin...
1. HEALTH BELIEF MODEL
This model proposes that an individual’s beliefs are
important determinants of his/her health-relat...
For example, a patient is instructed to wear an appliance or
a negative outcome will ensue (e.g. diminished esthetic
resul...
Finally, barriers to appliance use, such as concerns about
appearance or the complexity of the regimen, will
decrease the ...
In this theory, a person’s intention to engage in a
behavior that directly determines whether they
perform that behavior. ...
As in the health belief model, both internal events such as
attitudes and environmental factors including social
pressure ...
3. SELF-REGULATION THEORY
This theory suggests that individuals regulate their own
behavior using the following 3 processe...
Third, patients adjust their behavior depending on how it
Third
compares with these personal standards (“I am really not
d...
Self-efficacy has also been associated with increased
frequency of brushing and flossing. These finding suggest
that incre...
First stage is pre-contemplation, which people typically fails to
acknowledge the need for behavior change and have no
int...
An important implication of this model is that patients at
different stages will require different interventions assist
th...
Based on these theoretical models, the following
recommendations for clinical practice are suggested.
1. Assess patients’ ...
3. Be aware that the patient seek treatment at very different
points along the stage of change, and parents and children m...
When these barriers are identified, steps should be
taken to reduce the barriers or to tailor treatment
around the barrier...
DENTAL - FACIAL APPEARANCE AND SOCIAL
BEHAVIOUR
Self-perceptions of dental-facial appearance begin with
esthetic values sh...
Children who perceive themselves to be attractive will
reflect those perceptions in their behaviors and generally
will rec...
SHAW, MEEK AND JONES et al (BJO 1980) found that
children reported stronger feelings of upset when teased
about their dent...
ALBINO, LAWRENCE et al concluded that the effect of
orthodontic treatment on social behavior might be masked
by the matura...
FACTORS RELATED TO COOPERATION IN ORTHODONTIC
TREATMENT

Patient cooperation is the single most important factor every
ort...
What may be more interest to the orthodontist than the
shaping of self-perceptions is the shaping of behavior that
will en...
FACTORS RELATED TO COOPERATION IN TREATMENT

AGE
GENDER
TIME
PAIN
PATIENT /PARENTS RELATIONSHIP
SOCIOECONOMIC STATUS
PATIE...
1. AGE
The decision of whether to treat a patient in childhood or
adolescence raises several issues related to the develop...
Allan and Hodgson et al (AJO 1968) conducted a study
to predict patient cooperation with the use of
standardized measureme...
Tung and Kiyak et al (AJO 1998) looked at characteristic
of preadolescent orthodontic patients and suggested that
this gro...
Southard et al (AJO 1991) accounted that 24% of the
variance in compliance among a group of 104 teenage
orthodontic patien...
4. PAIN
Orthodontic patients experience pain and discomfort to a
varying degree during the course of treatment.
Sergl et a...
5. PATIENT /PARENT RELATIONSHIP
Parental concern most likely stems from the parents' hope that
the child will conform to t...
Kegeles et al reported that children whose parents
encouraged treatment were generally more co-operative
and found that un...
6. SOCIOECONOMIC GROUPS
Higher socioeconomic groups tend to cooperate more than
lower socioeconomic groups. This may be du...
Starnbach and Kaplan et al (ANGLE 1975) studied
demographic factors that were associated with cooperative
patients. They f...
Lewit et al (CHILD DEV 1968) examined behavioral
dispositions with severity of the malocclusion (mild
moderate and severe ...
And reported that those with an internal locus of control
cooperate better with orthodontic regimen than those
with an ext...
8. PARENTS PERCEPTION
The efforts to enhance cooperation of adolescent patients
in orthodontic treatment might be most pro...
9. ROLE OF ORTHODONTIST
It is important that orthodontist listen carefully to patients
and gain complete understanding as ...
CRITICAL FACTOR FOR COOPERATION IN ORTHODONTIC TREATMENT
PRE-TREATMENT

EARLY IN
TREATMENT

THROUGH
TREATMENT

CHILD

Perc...
COMPLIANCE
A seminal definition of compliance (or adherence) to which
many investigators have subscribed, was suggested by...
When a patient deviates from these therapeutic
recommendations, the presumption is that the likelihood of
achieving the de...
Self-Regulation Approach to Orthodontic Patient Compliance
Numerous theoretical models have been proposed to explain
patie...
The component parts of a simple self-regulation model for
patient compliance are:

First, the patient must understand the ...
Second, the patient must be able to monitor his or her
own behavior (Fig, part F) and determine how it
compares with' the ...
Third, if the actual behavior does not coincide with the clinical
recommendation (i.e., the definition of non-compliance),...
A regulatory model of patient compliance suggests that
poor compliance can result from a variety of factors
1. PATIENT DOE...
1. PATIENT DOES NOT KNOW THE THERAPEUTIC
REGIMEN
For example, if a patient does not know the therapeutic
recommendation an...
Orthodontists recognize these potential problems and thus
often write a description of the recommended regimen on
the outs...
2. UNAWARE OF THE RECOMMENDED REGIMEN
Another obstacle to compliance is that patients are often
unaware of how well they a...
In fact, Sahm et al have data indicating that self-reports
of not wearing an orthodontic appliance are likely to be
accura...
Strategies to repair the regulatory loop would require
patients to be aware of their own behavior so that it can be
compar...
3. POOR MOTIVATION OF PATIENT
Poor motivation can also contribute to non­compliance. The
regulatory loop requires a motiva...
Cognitive approaches that emphasize the personal relevance
of the regimen or address misconceptions about the treatment
ma...
Current orthodontic research focuses on a critical aspect of the
feedback; specifically, the input received by the compara...
Measuring Headgear Use
Orthodontists are understandably interested in the amount of
time a headgear is worn.
Typical clini...
Unfortunately, such methods are poor and commonly provide
an overestimate of compliance. There is a clear need for a
relia...
PREDICTING PATIENT COMPLIANCE IN
ORTHODONTIC TREATMENT
Consciously or intuitively, orthodontists always attempt at the
beg...
It would be preferable to develop reliable methods of
predicting the level of future compliance at the diagnostic
stage, w...
1. DEMOGRAPHIC ASPECT
In the search for potential predictors of treatment
compliance, considerable attention has been dire...
In contrast, studies by Albine and Sergl et al (EJO 1992)
have revealed no correlation between patients' age and the
level...
Studies by klima et al (AJO 1979) suggest that in
contrast to boys, girls tend to express lower body image
satisfaction an...
Socioeconomic status:
Several investigations have addressed the is­sue of
potential influence of patients' socioeconomic s...
Cucalon and Smith et al (ANGLE 1989) reported that
female patients from higher socioeconomic groups show
the highest compl...
Dorsey and Korabik et al (AJO1977) have indicated
superior compliance shown either by children of civil
servants compared ...
2. PSYCHOSOCIAL AND PSYCHOLOGIC ASPECTS
Considerable attention has been devoted to evaluation of
the effects of patients' ...
EDUCATION LEVEL:
Richter, Nanda and Sinha et al (ANGLE 1996) reported
that cooperative orthodontic patients tend to have b...
PARENTS ATTITUDE:
Mehra et al (ANGLE 1996) suggested that parental
beliefs are important for a child's compliance, and tha...
Study by Nanda and Kierl et al (AJO 1992) evaluated
several factors of potential relevance to compliance
prediction.
Treat...
PATIENTS PERSONALITY
Substantial evidence has accumulated suggesting that
patients' personality characteristics are import...
Specific psychologic diagnostic tests were used for
evaluation of patients' cooperation, responsibility,
reliability, and ...
PERSONALITY TEST
Personality tests have been used by a number of investigators,
generally with the goal of being able to p...
McDonald reported a significant correlation between
scores on the California Test of Personality and patient
cooperation.
...
Initial Experience With Orthodontics and Acceptance
of Treatment
As patients may experience a considerable amount of
disco...
Pain, functional and esthetic impairment, and
associated complaints are the principal reasons for the
patient's wish to di...
Effects of appliance type on oral complaints, such as higher
degree of pain or speech impairment during wearing of the
bio...
General personality variables and specific attitudes to
orthodontics seem to play an important role.
Sergl et al (AJO 1980...
ACHIEVING PATIENTS COMPLIANCE
Improving Patient Compliance in Orthodontic Practice.
Patient noncompliance is a limiting fa...
In addition, many of these "noncompliant" techniques have
now reverted back. E.g.,traditional methods of anchorage
control...
Many variables have been correlated with orthodontic
patient compliance. These variables have ranged from
different demogr...
Various prevention and improvement concepts that
can positively affect orthodontic patient compliance
are:
A shift from a ...
1. Patient-Centered Care versus Practitioner Centered Care
Traditionally, orthodontic treatment prescribed by the
practiti...
A patient­centered approach would place some of the
responsibility of successful patient compliance on the
practitioner. I...
Patient Education
Patient management may be greatly enhanced when patients
understand the nature of their condition and th...
At the same time, parents may not be clear about
treatment goals and mechanics. In addition, the parents'
ability to expla...
Various demonstration tools are available to aid in the education
process.
Good standard patient records such as study cas...
Patient Empowerment and Contracting Procedures
Educating patients regarding their condition gives them the
tools to make i...
Most often, alternatives are available and should be
offered following an understanding of the limitations
of different ap...
2. Patient's Causal Attributions
Patients attribute events in their lives to external and
internal causes. External causes...
Therefore, patients who attribute internally are better
compliers compared with those who attribute externally.
Those pati...
3. Patient Support at Home and at the Orthodontic
Office
Family support for the patient to follow pre­scribed
instructions...
An example is of patients who have to use the reverse
facemask headgear used for Class III skeletal growth
modification. T...
Methods of feedback to the patients can range from
completing report cards,
rewarding them for compliant behavior,
verbal ...
4. Rewarding Compliant Behavior
Improving patient compliance in day­to­day practice is
very challenging and often a comple...
A study carried out by Ritcher, Nanda and Sinha et al at
the University of Oklahoma revealed the following
findings regard...
5. Doctor/Patient Rapport and Communication
The successful practice of orthodontics is significantly
dependent on the inte...
Attention to the behavioral issues can greatly enhance the
rapport and can result in superior patient experiences and
trea...
CONCLUSION
Patients and parents place trust in orthodontist when they
seek treatment. They rely on you to tell them if the...
Thank you
For more details please visit
www.indiandentalacademy.com

www.indiandentalacademy.com
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Sem 5 behavior /certified fixed orthodontic courses by Indian dental academy

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The Indian Dental Academy is the Leader in continuing dental education , training dentists in all aspects of dentistry and offering a wide range of dental certified courses in different formats.

Indian dental academy provides dental crown & Bridge,rotary endodontics,fixed orthodontics,
Dental implants courses.for details pls visit www.indiandentalacademy.com ,or call
0091-9248678078

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Sem 5 behavior /certified fixed orthodontic courses by Indian dental academy

  1. 1. INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com www.indiandentalacademy.com
  2. 2. BEHAVIOUR CONSIDERATION DURING ORTHODONTIC TREATMENT www.indiandentalacademy.com
  3. 3. INTRODUCTION THEORIES OF PATIENT BEHAVIOUR PRATICAL IMPLICATIONS OF THEORIES DENTAL-FACIAL APPEARANCE AND SOCIAL BEHAVIOUR FACTORS INFLUENCING COOPERATION IN ORTHODONTIC TREATMENT CRITICAL FACTOR FOR COOPERATION IN ORTHODONTIC TREATMENT COMPLIANCE MODELS OF PATIENTS WITH COMPLIANCE PREDICTING PATIENTS COMPLIANCE ACHIEVING PATIENTS COMPLIANCE CONCLUSION www.indiandentalacademy.com
  4. 4. INTRODUCTION Behavioral dentistry is an interdisciplinary science, which needs to be learned, practiced and reinforced in the context of clinical care and within community oral health care system. The objective of this science is to develop in a dental practitioner an understanding of the interpersonal, intrapersonal, social forces that influence the patients’ behavior. The clinician must acquire knowledge to develop appropriate behavioral skills with an improved quality of communication and management of patients. Behavior dentistry also teaches to develop a recognition and understanding that the body and mind are not separate entities and focuses on patients’ social, emotional and physiological dental experiences. www.indiandentalacademy.com
  5. 5. Definition: Behavior is an observable act. It is defined as any change observed in the functioning of an organism. Learning as related to behavior is a process in which past experience or practice results in relatively permanent changes in an individual’s behavior. THEORIES OF PATIENT BEHAVIOUR MODELS OF HEALTH BEHAVIOR AND THEIR IMPLICATION FOR ORTHODONTIC TREATMENT 1. 2. 3. 4. HEALTH BELIEF MODEL THEORY OF PLANNED BEHAVIOR SELF-REGULATION THEORY STAGES OF CHANGE MODEL www.indiandentalacademy.com
  6. 6. 1. HEALTH BELIEF MODEL This model proposes that an individual’s beliefs are important determinants of his/her health-related behavior. Four sets of beliefs are thought to predict health-related behavior 1. Perceived susceptibility to disease or problem 2. Perceived severity of the problem 3. Perceived benefits of health behaviors, and 4. Perceived barriers to health-enhancing behaviors. www.indiandentalacademy.com
  7. 7. For example, a patient is instructed to wear an appliance or a negative outcome will ensue (e.g. diminished esthetic results). If the patient believes their susceptibility to that outcome is low, the patient is less likely to wear the appliance. Likewise, if the patient acknowledges that the outcome may occur, but judges this outcome to be low in severity, again engaging in the recommended behavior is improbable. On the other hand, if the patient behavior, that wearing the appliance will confer significant benefits, then the behavior is more likely. www.indiandentalacademy.com
  8. 8. Finally, barriers to appliance use, such as concerns about appearance or the complexity of the regimen, will decrease the frequency of the behavior. Thus efforts to improve compliance should address these patent beliefs through education, and barriers to compliance should be minimized while maximizing the perceived benefits of the behavior. 2. THEORY OF PLANNED BEHAVIOR This theory proposes that people are reasonable and make decisions about health-related behavior by using available information to achieve a desired goal. www.indiandentalacademy.com
  9. 9. In this theory, a person’s intention to engage in a behavior that directly determines whether they perform that behavior. Intention is influenced by 3 factors 1. The person’s attitude toward the behavior (e.g., “I don’t like wearing the cumbersome device that make me look different”), 2. Social influences on the behavior (“People will make fun of me”) 3. The person’s perceived behavioral control, which reflects a person’s perceived ability to overcome obstacles and is influenced by their past behavior. www.indiandentalacademy.com
  10. 10. As in the health belief model, both internal events such as attitudes and environmental factors including social pressure and perceived obstacles influence the behavior, but in Planned behavior they do so by determining whether the person intends to perform the behavior. Clear implication of this model is that assessing a patient’s intentions to adhere to the treatment regimen can be an important first step in identifying potential noncompliance. If intentions to change behavior are low, and then interventions to alter attitudes or increase behavioral control may be indicated. www.indiandentalacademy.com
  11. 11. 3. SELF-REGULATION THEORY This theory suggests that individuals regulate their own behavior using the following 3 processes: First, individual monitor both the determinants and First outcomes of their behavior. For example, a patient evaluates why he or she is wearing appliance (“Because the doctor told me to.”), and monitors the outcome of that behavior (“I feel like I’m taking good care of my teeth.”). Second, patients evaluate their behavior based on personal Second standards (“I’m doing pretty well for me.”) and environmental conditions (“Understands the circumstances, I can’t be expected to do much better.”) www.indiandentalacademy.com
  12. 12. Third, patients adjust their behavior depending on how it Third compares with these personal standards (“I am really not doing as well as I can”). Thus, this theory proposed reciprocal interactions among behavior, the environment and personal factors, such as internal standards and cognitive process. One central concept in self-regulation theory is self-efficacy, which refers to the belief that one can produce a desired outcome through one’s own efforts. www.indiandentalacademy.com
  13. 13. Self-efficacy has also been associated with increased frequency of brushing and flossing. These finding suggest that increasing a patient’s belief that he or she can successfully perform the behaviors requested (e.g. proper brushing, flossing and appliance use) can improve their adherence. 4. STAGES OF CHANGE MODEL This model proposes that people progress through 5 stages when making a behavior change, Broder and Phillips et al apply this model to understanding decisions regarding treatment www.indiandentalacademy.com
  14. 14. First stage is pre-contemplation, which people typically fails to acknowledge the need for behavior change and have no intention of changing their behavior. Second stage, contemplation, individuals recognize a need for stage change and are considering a change in behavior, but have not yet taken any steps in that direction. Third stage is preparation, and this stage involves making specific plans for behavior change. Fourth stage, action, involves implementing those plans, and stage this is the first stage in which overt behavior change occurs. The final stage is maintenance, in which people are attempting to sustain the behavior changes that they have made. www.indiandentalacademy.com
  15. 15. An important implication of this model is that patients at different stages will require different interventions assist them with behavior change. An important implication of each of these models is that patients’ attitude, thoughts, feelings, and perceptions are important determinants of their behavior. Therefore, clinicians must take these patient factors into account in order to provide optimal treatment. This is most effectively implemented through a patient-centered approach. www.indiandentalacademy.com
  16. 16. Based on these theoretical models, the following recommendations for clinical practice are suggested. 1. Assess patients’ intentions to adhere to treatment regimens (e.g. “How often do you plan to brush and floss?”). One can be relatively sure that if intentions to change behavior are low, then the likelihood of behavior change is also very low. In these instances, educational or behavioral interventions to increase intentions and promoter adhere will be needed. 2. Assess patients’ self-efficacy for successfully completing the prescribed treatment (e.g. “How capable do you feel you are of using this appliance as prescribed?”). If patients doubt their ability, then additional instruction and in office practice in the required behavior are indicated. www.indiandentalacademy.com
  17. 17. 3. Be aware that the patient seek treatment at very different points along the stage of change, and parents and children may also differ in their readiness for change. Treatment should be initiated only when the patient reports being ready to assume the responsibility and make the behavioral commitment required to successfully complete treatment. 4. Try to identify barriers to compliance with treatment recommendations. These may include personal characteristic of the patients (e.g. age, education level, socioeconomic status) or environmental factors, such as high levels of psychosocial stress or a lack of understanding the importance of treatment. www.indiandentalacademy.com
  18. 18. When these barriers are identified, steps should be taken to reduce the barriers or to tailor treatment around the barriers. 5. Treatment plans should incorporate the priorities and capabilities of the patient. This approach allows patients to participate in the decision making process and furthers the patient’s commitment. In cases in which patient decision conflicts with professional standards, limitations of the selected treatment plan should be presented. Options including non-treatment should be presented to the patient and parent. www.indiandentalacademy.com
  19. 19. DENTAL - FACIAL APPEARANCE AND SOCIAL BEHAVIOUR Self-perceptions of dental-facial appearance begin with esthetic values shared within families and based generally on social norms, but that they may be strongly influenced by peer values and specific experiences of individual children, particularly those involving social responses. Theories incorporating concepts of social comparison and self-efficacy suggest that the individuals evaluate themselves in comparison with other in their social environment. www.indiandentalacademy.com
  20. 20. Children who perceive themselves to be attractive will reflect those perceptions in their behaviors and generally will receive confirming social responses. The comparison group may express an attractiveness norm that reflects negatively on the individual’s behavior. This, inturn, can affect the individual perceived sense of self-efficacy or adequacy within that group and lead to behaviors that reflect more negative beliefs about the self, thereby inviting still more negative social responses. www.indiandentalacademy.com
  21. 21. SHAW, MEEK AND JONES et al (BJO 1980) found that children reported stronger feelings of upset when teased about their dental-facial appearance than when teased for some other reasons. Although there is probably some negative social feedback associated with more visible and less attractive forms of malocclusion, this relationship is confounded by the fact that malocclusion is not usually the major determinant of facial attractiveness. Consequently, when studies have attempted to identify positive in social behavior as a result of orthodontic treatment, such specific relationships are difficult to identify. www.indiandentalacademy.com
  22. 22. ALBINO, LAWRENCE et al concluded that the effect of orthodontic treatment on social behavior might be masked by the maturational trends of the age group studied. Positive changes in self-perceptions of dental-facial attractiveness and in others’ evaluations of dental-facial appearance were seen when adolescents who received orthodontic treatment were compared with those who did not. These young people believed that their dental-facial characteristic were more attractive as the result of treatment, and the self-assessments were consistent with objective evaluations of their appearance. www.indiandentalacademy.com
  23. 23. FACTORS RELATED TO COOPERATION IN ORTHODONTIC TREATMENT Patient cooperation is the single most important factor every orthodontist must contend with. Major considerations are Regularity in keeping appointments, Compliance in wearing rubber bands and headgear or wearing removable appliances, Refraining from chewing hard and tenacious substances that are likely to distort the arch wires and remove bonded brackets, and Maintenance of oral hygiene. Laxity in following these instructions may lead not only to compromised treatment but also to slow progress of treatment, loss of chair time, www.indiandentalacademy.com and frustration
  24. 24. What may be more interest to the orthodontist than the shaping of self-perceptions is the shaping of behavior that will ensure a successful result of treatment, that is, the patient’s adherence to prescribed routines for self-care and other regimens during orthodontic treatment. It is helpful in this regard to know that most patient expect improved dental-facial appearance as an outcome of treatment, but there is much more to know about factors influencing cooperation. www.indiandentalacademy.com
  25. 25. FACTORS RELATED TO COOPERATION IN TREATMENT AGE GENDER TIME PAIN PATIENT /PARENTS RELATIONSHIP SOCIOECONOMIC STATUS PATIENT PERCEPTION PARENTS PERCEPTION ROLE OF ORTHODONTIST www.indiandentalacademy.com
  26. 26. 1. AGE The decision of whether to treat a patient in childhood or adolescence raises several issues related to the developmental stages of preadolescence and adolescence. One of these issues is the concern with adherence. Treatment adherence is influenced by a child's age and sex. In general, girls are more likely to adhere to treatment recommendations than boys. Preadolescent children have been found to be more adherent to rules for the use of removable appliances than adolescents. For this reason it has been suggested that treatment begin after age 6 and be completed before the onset of puberty. Children experience major changes in these aspects of the self as they move from early childhood through the teen years. www.indiandentalacademy.com
  27. 27. Allan and Hodgson et al (AJO 1968) conducted a study to predict patient cooperation with the use of standardized measurements of personality. Each patient had been receiving treatment for a minimum of 1 year. They found that age was the single best predictor of patient cooperation. The younger patients tended to be more cooperative. Similarly, Weiss et al (AJO 1977) concluded that 12year-old and younger patients were more cooperative than older patients. However, even the younger patients were less cooperative in keeping appointments and in protecting appliances from breaking. www.indiandentalacademy.com
  28. 28. Tung and Kiyak et al (AJO 1998) looked at characteristic of preadolescent orthodontic patients and suggested that this group may be ideal candidates for treatment, in part because they are not yet dealing with the issues of identity, confusion and concerns about the acceptance of others. Albino et al suggested that age does not directly influence cooperation, but may some-how mediate the factors that are related to cooperation. 2. GENDER Nanda and Kierl et al (AJO 1992) in their study showed 1992 that female adolescent orthodontic patients generally show more cooperative behavior than their male counterpart. www.indiandentalacademy.com
  29. 29. Southard et al (AJO 1991) accounted that 24% of the variance in compliance among a group of 104 teenage orthodontic patients on the basis of gender and 7 variables constructed from modifications of the Million Adolescents Personality Inventory. Author concluded that female patients were more cooperative than male patients. 3. TIME The studies of influences on cooperation carried at Buffalo University by Albino et al showed that factors predicting cooperation within the first 10 months of orthodontic treatment differed from those predicting cooperation when appliance were removed, after an average of 26 months in active treatment. www.indiandentalacademy.com
  30. 30. 4. PAIN Orthodontic patients experience pain and discomfort to a varying degree during the course of treatment. Sergl et al (AJO 1998) investigations were to follow the progress of adaptation after insertion of new appliances and to study the relationships between the type of appliance worn and pain or discomfort experienced, between pain sensations and attitude toward the treatment and their effects on patients’ compliance. The results of this study indicated that acceptance of orthodontic appliances and treatment in general may be predicted by the amount of initial pain and discomfort experienced. This study supports earlier findings by Egolf and Begole (AJO 1990) that discomfort caused by orthodontic appliance may affect treatment compliance, and even lead to premature www.indiandentalacademy.com termination of treatment.
  31. 31. 5. PATIENT /PARENT RELATIONSHIP Parental concern most likely stems from the parents' hope that the child will conform to their own and society's ideals of facial attractiveness. It has been suggested that parental influence based on dental aesthetics, necessarily malocclusion severity may be the main motivating factor for children to seek orthodontic treatment. Kreit et al studied patient cooperation from a personality test administered by 120 dentists. He found that the most salient feature of uncooperative patients was the perception of poor relations with their parents. On the other hand, cooperative patients were rather conventional and conforming. www.indiandentalacademy.com
  32. 32. Kegeles et al reported that children whose parents encouraged treatment were generally more co-operative and found that un-cooperative patients typically had poor relationships with parents. Gross and Samson et al (AJO 1985) believe that because adolescents may have negative perceptions of orthodontic appliances, parental support is critical to treatment success. Albino et al (Jour Behavior Med 1994) reported that adolescent cooperation to be significantly and positively correlated with parent’s attitude. www.indiandentalacademy.com
  33. 33. 6. SOCIOECONOMIC GROUPS Higher socioeconomic groups tend to cooperate more than lower socioeconomic groups. This may be due to differences in values of facial esthetics. For example, higher socioeconomic groups may believe that malocclusion and the associated facial disharmony might have a social influence and could hinder their chances of obtaining jobs, running for public office, or succeeding in their social relationships. Dorsey and Korabik (AJO 1977) found that lower middle class patients considered orthodontic treatment to be more important than the upper middle class patients. Alley et al (AJO 1982) thought that regardless of socioeconomic status, facial appearance is probably the most important aspect of physical appearance that determines how others feel about us and how we feel about ourselves. www.indiandentalacademy.com
  34. 34. Starnbach and Kaplan et al (ANGLE 1975) studied demographic factors that were associated with cooperative patients. They found that female patients from moderate to lower socioeconomic groups were better patients. 7. PATIENT PERCEPTION Patients’ self-perception emerges from a history of experiences in face-to-face interactions that are interpreted in light of family and peer values and influences. Later on, it becomes more important on patients themselves, using strategies that focus on building their own sense of responsibility for results. www.indiandentalacademy.com
  35. 35. Lewit et al (CHILD DEV 1968) examined behavioral dispositions with severity of the malocclusion (mild moderate and severe malocclusion). They concluded that a patient's perception of their own malocclusion was a better predictor of cooperation than parent’s wishes and that of the orthodontist. El –Mangoury et al (AJO 1981) conducted a study based on Orthodontic Locus of Control Scale, adolescents who attributed responsibility for the outcome of their treatment to chance or to their orthodontist, rather than to themselves, were less likely to be viewed as cooperative over the long term of treatment. www.indiandentalacademy.com
  36. 36. And reported that those with an internal locus of control cooperate better with orthodontic regimen than those with an external locus of control. High-need achievers, high-need affiliators, and internally motivated patients were shown to be better cooperators. However, Albino et al reported patient cooperation was related to an external locus of control. www.indiandentalacademy.com
  37. 37. 8. PARENTS PERCEPTION The efforts to enhance cooperation of adolescent patients in orthodontic treatment might be most productively focused on the role of parent at the point when treatment is being considered and begun. Parents without previous experience related to orthodontic treatment will need information related to the treatment itself, to develop realistic expectations for treatment and an understanding of the patient’s role in treatment. Of particular interest is information about the consequence of not treating, or delaying treatment: such information will help the parent to place a relative value on the investment in treatment. www.indiandentalacademy.com
  38. 38. 9. ROLE OF ORTHODONTIST It is important that orthodontist listen carefully to patients and gain complete understanding as possible of how the patient views his or her occlusal problems. This involve asking questions about how the patient feel about his or her dental-facial attractiveness, what the expectations are for improvement, and whether there is any sense of pressure from parents, siblings or peers related to treatment. An acknowledgement of the patient’s perspective is critical to ensuring the development of treatment partnership. Within the relational context established by a sharing of goals, concerns, and expectations, the orthodontist can assist the patient in the development of perception of controls that will foster cooperative behavior www.indiandentalacademy.com
  39. 39. CRITICAL FACTOR FOR COOPERATION IN ORTHODONTIC TREATMENT PRE-TREATMENT EARLY IN TREATMENT THROUGH TREATMENT CHILD Perceives functional/ esthetic impairment Perceives need for treatment/desires treatment Develops realistic expectations Learning coping/control strategies Assumes control of behavior related to effect outcomes of treatment Shares responsibility for treatment outcomes PARENTS Perceives need for treatment Believes in efficacy of treatment Places high value on occlusion/treatment Enables treatment Takes interest in treatment Encourages homecare Supports and approves child’s active participations and responsibility in treatment ORTHODONTIST Professionally evaluates Engages parent and treatment needs patient in goals, Seeks to understand expectations patient and parent Acknowledges patient perceptions and parent perceptions Communicates goals, expectations, potential problems in treatment www.indiandentalacademy.com Develops partnership with patient Shares responsibility with patient for progress, setbacks, outcomes of treatment
  40. 40. COMPLIANCE A seminal definition of compliance (or adherence) to which many investigators have subscribed, was suggested by Haynes: Compliance is "the extent to which a person's Haynes behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice. Orthodontists ask patients to behave in ways that will maximize the likelihood of achieving the orthodontic treatment objectives. For example, patients are asked to keep their appointments, adhere to dietary restrictions, modify their oral hygiene practices, and follow complicated treatment regimens that include the use of elastics, headgears, and other removable appliances. www.indiandentalacademy.com
  41. 41. When a patient deviates from these therapeutic recommendations, the presumption is that the likelihood of achieving the desired goals is reduced. There are a myriad of strategies for dealing with patient noncompliance. The strategy a clinician chooses is often influenced by how he or she conceptualizes the cause(s) of poor compliance. An example of this comes from an early view of noncompliance that suggested it resulted from a character "flaw" that allowed an individual to deviate from a therapeutic regimen that was intended for his or her own benefit. www.indiandentalacademy.com
  42. 42. Self-Regulation Approach to Orthodontic Patient Compliance Numerous theoretical models have been proposed to explain patient noncompliance. One useful conceptualization of the general problem of patient noncompliance comes from selfregulation/ control theory. Self-regulation principles are being applied in diverse areas of clinical psychology and have been particularly useful in guiding work on compliance problems in orthodontics. Most patients begin clinical care with an explanation of how their health concern will be addressed by the recommended treatment. The patient is then given the responsibility of regulating his or her behavior so that it coincides with the therapeutic regimen. This process consists of a number of steps. www.indiandentalacademy.com
  43. 43. The component parts of a simple self-regulation model for patient compliance are: First, the patient must understand the regimen and have the ability to follow it (Fig, part A). Using an orthodontic example, a patient must know how to put on the headgear correctly as well as know the number of hours per day that it should be worn. www.indiandentalacademy.com
  44. 44. Second, the patient must be able to monitor his or her own behavior (Fig, part F) and determine how it compares with' the recommended behavior (Fig, part B). www.indiandentalacademy.com
  45. 45. Third, if the actual behavior does not coincide with the clinical recommendation (i.e., the definition of non-compliance), then this mismatch should generate an error signal (Fig, part C) that activates the patient's motivational system (Fig, part D) to correct the discrepancy by altering his or her behavior accordingly (Fig, part E). This is a description of a well-known regulatory control process www.indiandentalacademy.com known as a Negative Feedback Loop. Loop
  46. 46. A regulatory model of patient compliance suggests that poor compliance can result from a variety of factors 1. PATIENT DOES NOT KNOW THE THERAPEUTIC REGIMEN 2. PATIENT UNAWARE OF THE RECOMMENDED REGIMEN 3. POOR MOTIVATION OF PATIENT www.indiandentalacademy.com
  47. 47. 1. PATIENT DOES NOT KNOW THE THERAPEUTIC REGIMEN For example, if a patient does not know the therapeutic recommendation and/ or does not have the skill or dexterity to perform the recommended behavior, then poor compliance results. Orthodontic treatment can provide many good examples. An orthodontist's recommendation for intraoral elastic use some times changes during treatment in terms of location of elastic placement, duration of use, force of the elastic used, and number of elastics used at a time. Furthermore, patients must have sufficient training and manual dexterity to place intra-oral elastics. www.indiandentalacademy.com
  48. 48. Orthodontists recognize these potential problems and thus often write a description of the recommended regimen on the outside of the bag containing the elastics and teach patients how to place elastics. These are obvious requirements for a functional regulatory loop. When these requirements are not met, the ability to regulate one's behavior to coincide with a therapeutic recommendation is impaired. In this situation, a strategy to improve compliance would be to repair the feedback loop through patient education and training. www.indiandentalacademy.com
  49. 49. 2. UNAWARE OF THE RECOMMENDED REGIMEN Another obstacle to compliance is that patients are often unaware of how well they are following the recommended regimen. In orthodontics, patients are often asked the average number of hours per day that an appliance has been worn since the previous visit. This request requires patients to accurately recall, or to have kept records, of the cumulative wear time and then to divide that value by the number of days since the previous appointment. This calculation is simple if the patient has not used the appliance. www.indiandentalacademy.com
  50. 50. In fact, Sahm et al have data indicating that self-reports of not wearing an orthodontic appliance are likely to be accurate. However, for patients who are following the recommendation to some degree, calculating an accurate measure of average wear time can be a difficult task. It is less surprising that patient reports of average wear time are very inaccurate and resemble the clinical recommendation rather than the actual use of the appliance. Furthermore, having the ability to make this comparison is necessary for the operation of the feedback loop. www.indiandentalacademy.com
  51. 51. Strategies to repair the regulatory loop would require patients to be aware of their own behavior so that it can be compared with the recommendation. Evidence supporting the importance of this information indicates that patients who keep a written log of headgear wear are more adherent to the regimen. Asking patients to maintain a written log of their behavior can reduce some problems (e.g., poor recollection), but there is no guarantee that the data are a true representation of the behavior, and many patients do not adhere to the request to maintain a written log. www.indiandentalacademy.com
  52. 52. 3. POOR MOTIVATION OF PATIENT Poor motivation can also contribute to non­compliance. The regulatory loop requires a motivational system to adjust behavior to coincide with the recommended regimen. A patient may recognize that the regimen is not being followed and yet simply not be motivated to correct the discrepancy. Poor motivation can also result from a lack of concern over the long­term health consequences of one's behavior and/or a lack of belief in the treatment. www.indiandentalacademy.com
  53. 53. Cognitive approaches that emphasize the personal relevance of the regimen or address misconceptions about the treatment may enhance motivation. Several approaches may be useful in treating this cause of poor compliance. Providing incentives or rewards for compliant behavior might be a useful strategy to enhance motivation The cause of noncompliance is multifactorial and strategies to improve compliance must be tailored to fit each situation. www.indiandentalacademy.com
  54. 54. Current orthodontic research focuses on a critical aspect of the feedback; specifically, the input received by the comparator that quantifies the actual amount of adherent behavior. This aspect of the feedback loop is particularly problematic because when asked how many hours a headgear has been worn, patients do not know how to estimate the total. Likewise, orthodontists cannot reliably estimate the amount of wear and parents are not sure of their child's degree of appliance use. Patients, parents, and clinicians need a way to ascertain this information. Technology may provide the solution to this problem as it has in other areas of patient compliance. Research suggests that patients receiving feedback about their degree of compliance are better able to follow a recommended regimen. www.indiandentalacademy.com
  55. 55. Measuring Headgear Use Orthodontists are understandably interested in the amount of time a headgear is worn. Typical clinical methods for estimating the amount of headgear wear include:  evaluations of proxy measures of compliance (e.g., oral hygiene)  condition of the appliance (e.g., a worn­looking neck­ strap), mobility of the molar  ease of patient use, and  direct patient inquiry either verbally or by questionnaire. www.indiandentalacademy.com
  56. 56. Unfortunately, such methods are poor and commonly provide an overestimate of compliance. There is a clear need for a reliable method of measuring the time a headgear has been worn and there have been numerous attempts to pro­duce such a device. Northcutt introduced the first timing headgear in 1974. The timer consisted of 2 switches that were activated when the appliance was worn and accumulated wear time until the appliance was removed. A study by Banks and Read, found that only 4 of 13 head­ Read gear timers were accurate more than 90% of the time. www.indiandentalacademy.com
  57. 57. PREDICTING PATIENT COMPLIANCE IN ORTHODONTIC TREATMENT Consciously or intuitively, orthodontists always attempt at the beginning of treatment to estimate the level of compliance attainable for each individual patient during subsequent treatment stages. They are usually guided by the general impression gained from the first encounter with the patient and his or her family. To ensure efficient clinical management of orthodontic patients, it is desirable to identify factors, which would enable the orthodontist at the early stages of treatment to predict the patient's subsequent behavior and compliance. www.indiandentalacademy.com
  58. 58. It would be preferable to develop reliable methods of predicting the level of future compliance at the diagnostic stage, which could be appropriately considered during planning of individual treatment strategies. PREDICTING PATIENT COMPLIANCE DEMOGRAPHIC ASPECT PYSCHOSOCIAL ASPECT 1. Age 2. Gender 3. Socioeconomic status 1. Education 2. Parent’s attitude 3. Patient’s personality www.indiandentalacademy.com
  59. 59. 1. DEMOGRAPHIC ASPECT In the search for potential predictors of treatment compliance, considerable attention has been directed toward evaluation of patients' demographic characteristics. Patient Age: Allan et al (AJO 1968) studied that patient's age was found to be the best predictor of cooperation. Further, it was reported that higher levels of compliance may be expected from 12­year­old and younger orthodontic patients compared with adolescent patients. It is generally assumed that children 4 years of age are sufficiently receptive to permit successful orthodontic treatment. www.indiandentalacademy.com
  60. 60. In contrast, studies by Albine and Sergl et al (EJO 1992) have revealed no correlation between patients' age and the level of compliance, which is probably attributable to confounding effects of children's individual psychologic maturation. As orthodontic treatment is frequently concurrent with the period of adolescence, a potential influence of age on the compliance of this group of patients might at first appear to be meaningful. Gender: Kreit and Starnbach et al have emphasized that the patient's gender might help predict treatment compliance demonstrating that female patients tend to show better cooperation compared with males. www.indiandentalacademy.com
  61. 61. Studies by klima et al (AJO 1979) suggest that in contrast to boys, girls tend to express lower body image satisfaction and are more likely to be displeased, with their dental appearance. Whereas these characteristics might strengthen the motivation of girls to seek and accept orthodontic treatment, they might also prevent the same patients from wearing overtly visible appliances in public, such as removable appliances or headgear, and thus reduce compliance. www.indiandentalacademy.com
  62. 62. Socioeconomic status: Several investigations have addressed the is­sue of potential influence of patients' socioeconomic status on their compliance with orthodontic treatment. It has been proposed that offspring's from families belonging to higher socioeconomic groups tend to develop better treatment compliance, possibly based on the perception that attractive dentofacial appearance is a valuable asset for social and occupational success. www.indiandentalacademy.com
  63. 63. Cucalon and Smith et al (ANGLE 1989) reported that female patients from higher socioeconomic groups show the highest compliance levels. It appears from the results of other studies, however, that patients from lower middle class families show a higher appreciation of orthodontic treatment than those from the upper middle class, and that orthodontic patient from moderate and lower socioeconomic groups might develop better compliance. This has been attributed to a greater need for social acceptance and higher social aspirations as well as better child­parent relationships frequently found in these families. www.indiandentalacademy.com
  64. 64. Dorsey and Korabik et al (AJO1977) have indicated superior compliance shown either by children of civil servants compared with those of working class and self­ employed parents, or by children of factory workers in contrast to offspring's of intellectuals. In contrast Sergl et al (EJO 1992) reported, no evidence of potential effects of parental occupational status on children's compliance. Nevertheless, the importance of the knowledge of the patient's socioeconomic and cultural background should not be undervalued as it may serve as a useful adjunct to successful monitoring of treatment compliance. www.indiandentalacademy.com
  65. 65. 2. PSYCHOSOCIAL AND PSYCHOLOGIC ASPECTS Considerable attention has been devoted to evaluation of the effects of patients' psychologic traits and psychosocial background on compliance during orthodontic treatment. It is generally believed that patient's personality characteristics, his or her relationships with the family, peers and orthodontist, as well as performance at school are closely linked with compliance, and might serve as valuable sources of information regarding both prediction and management of compliance www.indiandentalacademy.com
  66. 66. EDUCATION LEVEL: Richter, Nanda and Sinha et al (ANGLE 1996) reported that cooperative orthodontic patients tend to have better grades and show less deviant behavior at school, they are less frequently truant from school, are considered academically brighter and more sociable by their teachers, and reveal higher levels of self­perceived cognitive competence. On these grounds, patients' scholastic performance might serve as a useful predictor of treatment compliance. Dausch and Neumann et al observations indicate that children of above­average intelligence are more cooperative during treatment, which, however, does not necessarily imply that children of below­average intelligence show poor compliance, because both variables appear to depend strongly on a number of other psychosocial factors. www.indiandentalacademy.com
  67. 67. PARENTS ATTITUDE: Mehra et al (ANGLE 1996) suggested that parental beliefs are important for a child's compliance, and that assessment of the child­parent relationship may help predict the level of cooperation. How­ever, it appears from other studies that a child's personal psychologic characteristics may be a more decisive factor determining the level of treatment compliance. Nevertheless, parents seem to play a prominent role in influencing a child's decision to seek orthodontic treatment, and parental attitudes influence the child's compliance in the earlier stages of treatment. www.indiandentalacademy.com
  68. 68. Study by Nanda and Kierl et al (AJO 1992) evaluated several factors of potential relevance to compliance prediction. Treatment­related psychosocial factors such as patient's and parents' treatment attitudes and expectations, or relationships between the child, parents and orthodontic practitioner, were investigated. These observations imply that development of an effective relationship between the orthodontist and the patient at the earliest stages of treatment is beneficial for future compliance, and that the orthodontist's perception of his or her interpersonal relationship with the patient may be useful in predicting compliance. www.indiandentalacademy.com
  69. 69. PATIENTS PERSONALITY Substantial evidence has accumulated suggesting that patients' personality characteristics are important for the individually attainable level of treatment compliance. Studies dealing with the psychologic assessment of patients undergoing orthodontic treatment have out­lined psychologic profiles of uncooperative and cooperative patients. Sergl et al compared extraordinarily cooperative orthodontic patients with patients rated by their clinicians as highly uncooperative. www.indiandentalacademy.com
  70. 70. Specific psychologic diagnostic tests were used for evaluation of patients' cooperation, responsibility, reliability, and endurance during treatment. The results indicated that irrespective of gender, the patients who tend to be uncooperative are inclined to attitudinal preferences conventionally regarded as masculine, which are expressed as active, aggressive, and realistic behavioral patterns and self­images, rather than sensitive, esthetic and idealistic ones. Allan and Hodgson (AJO 1968) reported that patients more likely to show higher levels of treatment compliance are enthusiastic, outgoing, energetic, self­ controlled, responsible, trusting, diligent, and obliging persons. www.indiandentalacademy.com
  71. 71. PERSONALITY TEST Personality tests have been used by a number of investigators, generally with the goal of being able to predict patient cooperation by identifying particular personality types. Both Gabriel and McDonald used the California Test of Personality. This test purports to measure a number of psychosocial domains, such as self­reliance, sense of personal worth, or social skills. Gabriel (ANGLE 1965) found a low correlation between the scores from items of the California Test of Personality and a post treatment, subjective assessment of motivation. He believed this correlation was too low to be predictive. www.indiandentalacademy.com
  72. 72. McDonald reported a significant correlation between scores on the California Test of Personality and patient cooperation. Southard and Tolley (AJO 1991) examined the feasibility of using a commercially available adolescent personality test to predict the behavior of adolescent patients in an orthodontic practice. Specifically, this study tested 1. the use of the Million Adolescent Personality Inventory (MAPI) as an appropriate instrument for an adolescent orthodontic population and 2. the correlation between MAPI test results and orthodontic compliance. Authors concluded that the MAPI has potential as a useful instrument in assisting the management of adolescent patient behavior in www.indiandentalacademy.com an orthodontic practice.
  73. 73. Initial Experience With Orthodontics and Acceptance of Treatment As patients may experience a considerable amount of discomfort from orthodontic treatment it is reasonable to expect that patients' initial experience with orthodontic treatment, adaptation to it and its acceptance at an early stage might strongly influence the degree of compliance at the subsequent stages. It is recognized that insertion of a new orthodontic appliance may diminish cooperation by causing considerable discomfort such as unpleasant tactile sensations, feeling of constraint in the oral cavity, stretching of the soft tissues, pressure on the oral mucosa, displacement of the tongue, sore­ness of the teeth and www.indiandentalacademy.com pain.
  74. 74. Pain, functional and esthetic impairment, and associated complaints are the principal reasons for the patient's wish to discontinue treatment. The patient's self­confidence might be affected by speech impairment and visibility of the appliance, especially during social interactions when attention is focused on the face, eyes and mouth. www.indiandentalacademy.com
  75. 75. Effects of appliance type on oral complaints, such as higher degree of pain or speech impairment during wearing of the bionator and the head­gear, increased incidence of perceived pain, tension, sensitivity, and pressure under treatment with functional and fixed appliances, or differences in initial acceptance of various designs of functional appliances, have been described for non­ compliance. It seems likely that because of different experiences encountered, the type of appliance may have a substantial effect on initial adaptation and should also be considered in compliance prediction. www.indiandentalacademy.com
  76. 76. General personality variables and specific attitudes to orthodontics seem to play an important role. Sergl et al (AJO 1980) indicated that patients' attitudes toward orthodontics at the beginning of treatment may predict their capability to accommodate to initial discomfort associated with an orthodontic appliance, which in turn, may predict the patient's acceptance of the appliance and the degree of subsequent compliance. Appliance adaptation and treatment acceptance or denials are short­ term events occurring within a few days after the initiation of treatment. This evidence suggests that attention of the treating clinician to patients' adaptation is necessary at the earliest treatment stages, to ensure and enhance future compliance. www.indiandentalacademy.com
  77. 77. ACHIEVING PATIENTS COMPLIANCE Improving Patient Compliance in Orthodontic Practice. Patient noncompliance is a limiting factor in the conversion of accurate orthodontic treatment plans to excellent treatment results. A variety of treatment techniques have been devised to overcome this barrier in the attempt at obtaining good results. Despite earlier claims made by the proponents of these techniques, it is abundantly clear that none of these techniques are completely successful without the patient's participation. www.indiandentalacademy.com
  78. 78. In addition, many of these "noncompliant" techniques have now reverted back. E.g.,traditional methods of anchorage control by headgear and elastics for a portion of the treatment period. Factors Influencing Orthodontic Patient Compliance During the initial treatment stages, the parent's positive attitudes toward orthodontic treatment predict patient compliance. In the later stages, the patient's own cognition regarding treatment directly correlates with compliance levels. Those patients who believe that their actions directly lead to superior treatment results are better compliers compared with those who believe that they do not have control over treatment outcomes. www.indiandentalacademy.com
  79. 79. Many variables have been correlated with orthodontic patient compliance. These variables have ranged from different demographic factors to those related to personality type and desire for treatment. The parent's previous orthodontic experience can be a positive influence on patient compliance. Also, when financial implications for noncompliance are presented during orthodontic treatment, parental influence on their child's performance may increase. In addition to patient and parent variables, studies have shown strong associations of the doctor­patient relationship with patient satisfaction and compliance. www.indiandentalacademy.com
  80. 80. Various prevention and improvement concepts that can positively affect orthodontic patient compliance are: A shift from a practitioner­centered model of patient care to a patient­centered approach is emphasized. It include: 1. 2. 3. 4. 5. Patient­centered care versus practitioner­centered care, Patient’s causal attributions, Patient support at home and at the orthodontic office, Rewarding compliant behavior, and Doctor­patient rapport and communication www.indiandentalacademy.com
  81. 81. 1. Patient-Centered Care versus Practitioner Centered Care Traditionally, orthodontic treatment prescribed by the practitioner based on defined professional standards without considering the priorities and capabilities of the patient. Patients who fail to follow prescribed instruction are labeled as "noncompliant." This is often done without considering the fact that the treatment prescribed may not have taken into account the capabilities, motivations, and expectations of each individual patient. Hence, patients have had to bear the burden and the outcome of noncompliance rather than considering the inability of the practitioner to understand individual patient needs and to make appropriate treatment plans. www.indiandentalacademy.com
  82. 82. A patient­centered approach would place some of the responsibility of successful patient compliance on the practitioner. In this model, the practitioner would prescribe treatment plans based on individual patient expectations, priorities, and capabilities Repeated treatment progress re­evaluations and patient/parent consultations are a key component of success in this proposed model. In the orthodontic treatment realm, key issues that relate to this concept fall within the following: (1) Patient education and (2) Patient empowerment and contracting procedures. www.indiandentalacademy.com
  83. 83. Patient Education Patient management may be greatly enhanced when patients understand the nature of their condition and the proposed treatment plan or procedure to be performed. Educating the patient regarding his or her malocclusion and the means to achieve an acceptable result is very important to success in motivating the patient to succeed. Often treatment is prescribed for patients who have limited or no understanding of their orthodontic problem and why some aspects of treatment mechanics are necessary for successful outcomes. www.indiandentalacademy.com
  84. 84. At the same time, parents may not be clear about treatment goals and mechanics. In addition, the parents' ability to explain details of the condition and the necessity for different appliances to their children may also be limited. The result is a patient who is less likely to achieve a successful treatment outcome. A strong effort to educate patients regarding their condition will allow them to make informed choices regarding appliance selection and the limitations of their selection. As treatment progresses, the' education component needs to be revisited to ensure their complete understanding. This will result in individuals who take greater responsibility for their actions during orthodontic treatment. www.indiandentalacademy.com
  85. 85. Various demonstration tools are available to aid in the education process. Good standard patient records such as study casts and photo­ graphs can be used to describe the problem. A presentation customized for the patient by different commercially available computer software programs is an excellent method for explaining mechanics and appliances. The use of demonstration models and appliances are important for the patient to completely understand different appliances. In addition, the practitioner can prepare a database of examples that can be digitally stored and used for these presentations. www.indiandentalacademy.com
  86. 86. Patient Empowerment and Contracting Procedures Educating patients regarding their condition gives them the tools to make informed decisions. The individual feels involved in the process of selecting what is most suited for the necessary change. Sometimes the patient's decision conflicts with their best interests and also goes against the wishes of the parents regarding possible outcomes. In these situations, flexible treatment strategies need to be devised in order to succeed. A compromise treatment plan may offer the best solution in some instances. In other situations, a suggestion to postpone treatment or the decision to withdraw from seeking treatment may solve the conflict. www.indiandentalacademy.com
  87. 87. Most often, alternatives are available and should be offered following an understanding of the limitations of different approaches. Once a decision has been reached using this process, the patient is empowered and selects a treatment option from choices offered. This process obligates the patients to comply with a previously reached agreement. A contract made with each individual patient has been shown to be successful in improving compliance in different areas of orthodontic care. www.indiandentalacademy.com
  88. 88. 2. Patient's Causal Attributions Patients attribute events in their lives to external and internal causes. External causes are outside of their control (external locus of control), versus internal, which are within their control (internal locus of control). El--Mangoury et al (AJO1981) found that orthodontic patients who attributed outcomes to internal causes were significantly more cooperative. Albino et al (J Behav Med1991) also found that those patients who attributed responsibility for their orthodontic condition and treatment externally to either chance or their orthodontists showed lower levels of compliance scores compared with others. www.indiandentalacademy.com
  89. 89. Therefore, patients who attribute internally are better compliers compared with those who attribute externally. Those patients who make fewer external attributions possess a sense of responsibility and consequences consequently believe that their participation and cooperation facilitates treatment progress. These findings can be used clinically to improve patient compliance by initially developing strong relationships and a high level of communication with patients. Good rapport along with patient education can empower patients to make informed decisions regarding their role in determining the success of treatment. www.indiandentalacademy.com
  90. 90. 3. Patient Support at Home and at the Orthodontic Office Family support for the patient to follow pre­scribed instructions is necessary for successful implementation of this program. Also, continuous encouragement and feedback from the orthodontic office is significant in creating a supportive environment, which is important for the patient. Patients are often required to wear cumbersome appliances that are difficult to use. If a difficult task is suddenly introduced requiring substantial effort from the patient, a noncompliance problem is created. www.indiandentalacademy.com
  91. 91. An example is of patients who have to use the reverse facemask headgear used for Class III skeletal growth modification. The headgear appears as a complicated device to the patient. This appliance has to be worn for a long period of time for successful correction. Often a rapid palatal expander is used in combination with this appliance. The patients should be started with the expansion device for 2 weeks followed by introducing the headgear gradually. The initial wear may be for I or 2 hours and progress to 4 hours in 3 to 4 weeks. The wear should progress to 12 to 14 hours of wear as dictated by the treatment plan. This method of gradually introducing tasks to patients may help them in their adaptation to newer difficult tasks. www.indiandentalacademy.com
  92. 92. Methods of feedback to the patients can range from completing report cards, rewarding them for compliant behavior, verbal praise, to regular patient/parent consultations. In addition, charted notations, which are highly visible to patients, can also affect compliance. Knerim et al (JCO 1992) www.indiandentalacademy.com
  93. 93. 4. Rewarding Compliant Behavior Improving patient compliance in day­to­day practice is very challenging and often a complex problem. Behavior modification by way of a re­ward program can be effective in improving patient compliance to prescribed instructions. In the orthodontic literature, recommendations of establishing a reward program to motivate patients and improve patient compliance have been cited. www.indiandentalacademy.com
  94. 94. A study carried out by Ritcher, Nanda and Sinha et al at the University of Oklahoma revealed the following findings regarding the use of awards as a motivating tool: 1. The award/reward program resulted in improvement in patient compliance scores in below average compliers as reflected in the improvement of oral hygiene scores. 2. Above average compliers remained above average throughout the length of the study. Below average compliers improved with re­wards, however, they never reached the compliance levels achieved by the above average compliers. It was concluded that rewards could be a means of positive feedback for patients in the orthodontic treatment of malocclusions www.indiandentalacademy.com
  95. 95. 5. Doctor/Patient Rapport and Communication The successful practice of orthodontics is significantly dependent on the interaction between the orthodontist and patient. Therefore, it is important to improve this relationship for superior treatment outcomes, patient satisfaction, and doctor satisfaction. In the busy orthodontic practice, it is often difficult to establish a close rapport with the patient. Better doctor/ patient communication can result in increased and more accurate transfer of information, thus improving the quality of care. The patient's perception that the orthodontist paid attention and took seriously what the patient had to say is significantly related to superior doctor/patient relationships. Making the patient feel welcome is also a significant factor in www.indiandentalacademy.com establishing this rapport.
  96. 96. Attention to the behavioral issues can greatly enhance the rapport and can result in superior patient experiences and treatment results. Improving doctor/patient/parent communication is an important factor in improving patient compliance as reported by practicing orthodontists. Mehra et al (ANGLE 1998) www.indiandentalacademy.com
  97. 97. CONCLUSION Patients and parents place trust in orthodontist when they seek treatment. They rely on you to tell them if the treatment is essential. All your patients will not finish treatment successfully. This is always not your fault. Lack of patient co­operation and vagaries of growth sometimes mitigate success. It is an alert orthodontist who recognizes the emotional reactions of the patient and not only treating malocclusion but also psychological fears, frustrations and behavior. The principle of knowing as much as possible about the patient, his family and his environment is a must that all practitioners should keep in mind, for dentistry, like medicine, recognize the therapy is not really successful www.indiandentalacademy.com unless the whole patient is treated.
  98. 98. Thank you For more details please visit www.indiandentalacademy.com www.indiandentalacademy.com

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