BEHAVIOUR CONSIDERATION

DURING ORTHODONTIC TREATMENT

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

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.

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
individuals 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

1. HEALTH BELIEF MODEL

This model proposes that an individuals 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.

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.

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.

In this theory, a persons intention to engage in a

behavior that directly determines whether they
perform that behavior. Intention is influenced by 3
factors
1. The persons attitude toward the behavior (e.g.,
I dont like wearing the cumbersome device
that make me look different),
2. Social influences on the behavior (People will
make fun of me)
3. The persons perceived behavioral control,
which reflects a persons perceived ability to
overcome obstacles and is influenced by their
past behavior.

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 patients
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.

3. SELF-REGULATION THEORY
This theory suggests that individuals regulate their own
behavior using the following 3 processes:
First,
First individual monitor both the determinants and
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 Im taking good care of my teeth.).
Second,
Second patients evaluate their behavior based on personal
standards (Im doing pretty well for me.) and
environmental conditions (Understands the circumstances,
I cant be expected to do much better.)

Third,
Third patients adjust their behavior depending on how it
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 ones own efforts.

Self-efficacy has also been associated with increased

frequency of brushing and flossing. These finding suggest
that increasing a patients 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

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,
stage contemplation, individuals recognize a need for
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,
stage action, involves implementing those plans, and
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.

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.

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.

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.

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 patients 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.

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.

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 individuals 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.

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.

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.

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,
and frustration

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
patients 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.

FACTORS RELATED TO COOPERATION IN TREATMENT

AGE
GENDER
TIME
PAIN
PATIENT /PARENTS RELATIONSHIP
SOCIOECONOMIC STATUS
PATIENT PERCEPTION
PARENTS PERCEPTION
ROLE OF ORTHODONTIST

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.

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.

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)
1992 in their study showed
that female adolescent orthodontic patients generally show
more cooperative behavior than their male counterpart.

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.

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
termination of treatment.

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.

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 parents attitude.

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.

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.

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 parents 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.

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.

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 patients 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.

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 patients
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

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

childs active
participations and
responsibility in
treatment

ORTHODONTIST

Professionally evaluates
treatment needs
Seeks to understand
patient and parent
perceptions
Communicates goals,
expectations, potential
problems in treatment

Engages parent and

patient in goals,
expectations
Acknowledges patient
and parent perceptions

Develops partnership
with patient
Shares responsibility
with patient for progress,
setbacks, outcomes of
treatment

COMPLIANCE
A seminal definition of compliance (or adherence) to which
many investigators have subscribed, was suggested by
Haynes:
Haynes Compliance is "the extent to which a person's
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.

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.

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.

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.

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).

Third, if the actual behavior does not coincide with the clinical
recommendation (i.e., the definition of noncompliance), 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
known as a Negative Feedback Loop.
Loop

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

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.

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.

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.

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.

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.

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 long-term health consequences of one's behavior and/or a
lack of belief in the treatment.

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.

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.

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 worn-looking neckstrap), mobility of the molar
ease of patient use, and
direct patient inquiry either verbally or by questionnaire.

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,
Read found that only 4 of 13 head
gear timers were accurate more than 90% of the time.

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.

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. Parents attitude
3. Patients personality

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 12-year-old 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.

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.

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.

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.

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 child-parent relationships frequently found
in these families.

Dorsey and Korabik et al (AJO1977) have indicated

superior compliance shown either by children of civil
servants compared with those of working class and selfemployed 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.

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

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 self-perceived 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 above-average intelligence are more cooperative
during treatment, which, however, does not necessarily imply
that children of below-average intelligence show poor
compliance, because both variables appear to depend
strongly on a number of other psychosocial factors.

PARENTS ATTITUDE:
Mehra et al (ANGLE 1996) suggested that parental
beliefs are important for a child's compliance, and that
assessment of the child-parent 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.

Study by Nanda and Kierl et al (AJO 1992) evaluated

several factors of potential relevance to compliance
prediction.
Treatment-related 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.

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.

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 self-images, 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, selfcontrolled, responsible, trusting, diligent, and obliging
persons.

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 self-reliance, 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.

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 an orthodontic practice.

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 pain.

Pain, functional and esthetic impairment, and

associated complaints are the principal reasons for the
patient's wish to discontinue treatment.
The patient's self-confidence 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.

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.

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.

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.

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.

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 doctor-patient
relationship with patient satisfaction and compliance.

Various prevention and improvement concepts that can

positively affect orthodontic patient compliance are:
A shift from a practitioner-centered model of patient care
to a patient-centered approach is emphasized. It include:
1.
2.
3.
4.
5.

Patient-centered care versus practitionercentered care,

Patients causal attributions,
Patient support at home and at the orthodontic office,
Rewarding compliant behavior, and
Doctor-patient rapport and communication

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.

A patient-centered 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
re-evaluations
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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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)

4. Rewarding Compliant Behavior

Improving patient compliance in day-to-day 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.

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

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 establishing this rapport.

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)

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
unless the whole patient is treated.