Adult orthodontic patients: What is important to them?

OBJECTIVE: To understand patients' motivations for pursuing treatment, to appreciate what information patients seek and to explore potential factors affecting decision making in adults considering, undergoing or who have had orthodontic treatment in the private sector. DESIGN: Cross-sectional questionnaire study. SETTING: Online questionnaire. PARTICIPANTS: A total of 209 (83% women, 16% men, 1% preferred not to say) completed responses were received. METHODS: Once piloted, the final survey was made available online to adults in the United Kingdom (UK) and Republic of Ireland (RoI) who were either considering having orthodontic treatment, currently undergoing treatment or had recently completed treatment in the private sector. RESULTS: The most commonly selected motivating factor was to 'improve the appearance of my teeth' (82%). The information sought related predominantly to treatment duration (64%), potential end results (56%), types of appliances that were available (55%) and cost (52%). The two most commonly reported social factors that had influenced participants to consider treatment were 'seeing myself on social media' (31%) and 'it is more socially acceptable to have braces' (31%). CONCLUSION: While this area remains relatively underexplored in the literature, it is crucial to develop a comprehensive understanding due to the increasing number of adults seeking orthodontic treatment. This study not only reinforces the existing knowledge regarding adults seeking orthodontic treatment, such as the predominant role of aesthetics as a motivating factor, but also introduces some novel insights. Specifically, we highlight the influence of social factors on decision-making processes and the importance of effectively communicating the duration of treatment to patients.

Late-forming supernumerary teeth: A case series.

The aim of this case series was to illustrate the development of late-forming supernumerary teeth (LFST) and highlight the implications for orthodontic treatment. There are limited studies relating to the aetiology, prevalence and treatment of LFST and the cases presented here demonstrate the management of LFST within a tertiary care centre. Five cases are presented, which show various presentations and chronological ages in the development of LFST. This case series emphasises the significance of maintaining a low threshold for suspecting LFST in patients where supernumerary teeth have previously been identified. It also highlights the importance of regular clinical and radiographic reviews. Timely identification can help prevent complications and optimise treatment outcomes.

Development, implementation and feedback for an online speciality membership examination in orthodontics during the COVID-19 pandemic.

Introduction The Royal College of Surgeons of England (RCSEng) and the Royal College of Physicians and Surgeons of Glasgow (RCPSG) offer the bi-collegiate Membership in Orthodontics (MOrth) examination, a summative assessment of specialist knowledge, skill and behaviour in orthodontics. The COVID-19 pandemic has had a profound global effect on almost every facet of normal life, including the conduct of face-to-face examinations. We highlight development, implementation and feedback for the bi-collegiate MOrth Part 2 examination delivered remotely to a cohort of candidates in September 2020 by RCSEng/RCPSG.Methods Two anonymised online surveys (Google Forms) were distributed via electronic mail following completion of the examination diet. Forty-two candidates were sent a survey covering four domains and comprising a total of 31 questions. The 20 examiners were sent a survey containing eight questions. In both surveys, free-text responses were also collected. A rating system was used to categorise responses. All survey responses were summarised in an online data collection sheet.Results The response rate was 78.5% (33/42) and 75% (15/20) for candidates and examiners, respectively. Overall, favourable responses in relation to all sections of the assessment were elicited from candidates with the majority (mean 79.8%; 75.8-81.9%) reporting that the online examination format worked well. Equally, favourable responses were reported by examiners. Notably, 80% of examiners felt that the online exam style did not affect the mark a candidate would receive, and 100% were confident that the marks the candidates received were a reflection of their ability and were not affected by the online delivery of the assessment.Conclusions The feedback from both candidates and examiners relating to an online remote assessment of the bi-collegiate MOrth Part 2 was generally positive. Based on the survey responses, this format of a high-stakes examination was acceptable to all stakeholders, and demonstrated a high level of perceived validity and reliability in terms of content.

Patient, clinician and independent observer perspectives of shared decision making in adult orthodontics.

OBJECTIVES: To investigate and compare the extent of shared decision making (SDM) in orthodontics from the perspective of patients, clinicians and independent observers. DESIGN: A cross-sectional, observational study. SETTING: NHS teaching hospital. PARTICIPANTS: A total of 31 adult patients and their treating clinicians were included in the study. METHODS: The extent of SDM in new patient orthodontic consultations was measured using three versions of a validated instrument: the self-administered patient dyadic-OPTION scale; the self-administered clinician dyadic-OPTION scale; and an independent observer-rated OPTION12 scale. Patients and clinicians completed the 12-item dyadic-OPTION questionnaire independently at the end of the consultation to rate their perceived levels of SDM. The consultations were also audio-recorded and two calibrated raters independently rated the extent of SDM in these consultations using the OPTION12 scale. RESULTS: There was excellent inter-rater reliability between the two independent raters using the OPTION12 scale (intraclass correlation coefficient (ICC) = 0.909). The mean patient, clinician and independent observer OPTION scores for SDM were 90.4% (SD 9.1%, range 70.8% to 100%), 76.2% (SD 8.95%, range 62.5% to 95.8%) and 42.6% (SD 17.4%, range 13.5% to 68.8%), respectively. There was no significant correlation between the OPTION scores for the three groups (ICC = -0.323). CONCLUSIONS: The results showed that generally high levels of SDM were perceived by patients and clinicians but lower levels of SDM were scored by the independent observers. However, it could be argued that the patient's perception of SDM is the most important measure as it is their care that is affected by their involvement.

Investigating perceptions of patient-centred care in orthodontics.

OBJECTIVES: To assess and compare patient and clinician perceptions of patient-centredness for adults about to commence active orthodontic treatment, and to assess whether the following variables affected perceptions of patient-centredness: patient gender and age; clinician gender and grade; and stage of treatment. DESIGN: A prospective, cross-sectional questionnaire study. SETTING: Eastman Dental Hospital, UCLH NHS Foundation Trust. PARTICIPANTS: A total of 112 adult patients and 30 clinicians completed 224 questionnaires (112 patient and 112 clinician questionnaires). METHODS: A validated, dyadic questionnaire, the '9-Item Patient Perception of Patient-Centredness' (PPPC), was used to collect data from both patients and their corresponding clinicians after initial assessment or records/treatment planning consultations. Total PPPC scores (possible score range = 9-36) were calculated for each patient and clinician to ascertain the extent to which they perceived they were engaging in patient-centredness, where higher scores corresponded with better performance. RESULTS: Patients and clinicians perceived high engagement in patient-centredness with median scores of 32/36 and 29/36, respectively. There was a statistically significant difference between total scores with patients perceiving consultations to be more patient-centred than clinicians (P < 0.001). None of the variables (patient gender and age, clinician gender and grade, stage of treatment) were statistically significant. CONCLUSION: Patients and clinicians both perceived high engagement in patient-centredness. Patients perceived consultations to be significantly more patient-centred than clinicians (P < 0.001).

A cross-sectional study investigating patients' preferences regarding shared decision-making in adult orthodontic patients.

Introduction Shared decision-making (SDM) is a process by which patients and clinicians work collaboratively to make decisions about healthcare. Previously, research has shown that patients want to be more involved in decisions about their care, but more recent evidence suggests that some patients may not wish to have the level of involvement that is now expected of them.Aims This study therefore investigated adult orthodontic patients' preferred and perceived roles in treatment decision-making.Methods This cross-sectional study was carried out in a teaching hospital using the Control Preferences Scale (CPS). This involved asking patients to choose one of five cards relating, firstly, to their preferred role in orthodontic decision-making, and then their perceived role in their current orthodontic treatment decision-making, and these were compared.Results One hundred patients were recruited and perceived roles in decision-making tended to be more passive than those patients said they preferred. Males were significantly more likely to select a passive role than females (p = 0.018).Conclusions Adult orthodontic patients perceived a more passive role in their current treatment decisions than they would have preferred. This highlights the importance of clinicians asking patients about their preferred role in treatment decision-making from the outset.

Factors influencing satisfaction with the process of orthodontic treatment in adult patients.

INTRODUCTION: Despite the increases in adults undergoing orthodontic treatment in both the public and private sectors, satisfaction with the treatment process has not been widely explored. In this study, we investigated factors influencing satisfaction with the process of orthodontic treatment in adult patients. METHODS: This was a prospective cross-sectional qualitative study. Participants were adults who had completed orthodontic treatment with fixed appliances and were recruited from 2 sites (a National Health Service public sector teaching hospital and a private specialist practice). Data were collected using in-depth interviews, and a content thematic analysis with a framework approach was used to analyze the data. RESULTS: A total of 26 adults were recruited (13 at each site). Five main themes were identified relating to patient satisfaction with the process of treatment: communication, staff, physical environment, appointments, and impact of appliance treatment. Effective communication was a dominant theme, particularly relating to explanations during treatment and making patients feel involved in their own care. CONCLUSIONS: In general, adult orthodontic patients were satisfied with the process of treatment, and good communication played a major part in this. Despite the differences in working models in the public and private sectors, many similarities arose when comparing the factors between the 2 sites.

Early treatment of class III malocclusion with facemask.

Data sourcesThe Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Embase, Medline and the ClinicalTrials.gov databases.Study selectionRandomised controlled trials (RCTs) and controlled clinical trials (CCTs) of children aged 7-12 years with class III malocclusion undergoing fixed or removable orthodontic treatment for early correction were included.Data extraction and synthesisTwo reviewers independently selected studies, abstracted data and assessed risk of bias. The Cochrane risk of bias tool was used for RCTs and the Downs and Black and the Newcastle-Ottawa scales for CCTs. The primary outcome was correction of reverse overjet. Mean differences (MD) with 95% confidence intervals were calculated and a random effects meta-analysis conducted.ResultsFifteen studies (nine RCTs, six CCTs) were included. Only three of the RCTs were considered to be at low risk of bias, all six CCTs were at high risk of bias.Three RCTs (141 patients) compared protraction facemask and untreated control. The results for reverse overjet (MD = 2.5 mm; 95% CI, 1.21-3.79) and ANB angle (MD = 3.90˚; 95% CI, 3.54-4.25) were statistically significant favouring the facemask group. All CCTs demonstrated a statistically significant benefit in favour of the use of each appliance. However, the studies had high risk of bias.ConclusionsThere is a moderate amount of evidence to show that early treatment with a facemask results in positive improvement for both skeletal and dental effects in the short term. However, there was lack of evidence on long-term benefits. There is some evidence with regard to the chincup, tandem traction bow appliance and removable mandibular retractor, but the studies had a high risk of bias. Further high-quality, long-term studies are required to evaluate the early treatment effects for Class III malocclusion patients.

Randomized controlled trial of a patient decision-making aid for orthodontics.

INTRODUCTION: Patient decision-making aids (PDAs) are instruments that facilitate shared decision making and enable patients to reach informed, individual decisions regarding health care. The objective of this study was to assess the efficacy of a PDA compared with traditional information provision for adolescent patients considering fixed appliance orthodontic treatment. METHODS: Before treatment, orthodontic patients were randomly allocated into 2 groups: the intervention group received the PDA and standard information regarding fixed appliances, and the control group received the standard information only. Decisional conflict was measured using the Decisional Conflict Scale, and the levels of decisional conflict were compared between the 2 groups. RESULTS: Seventy-two patients were recruited and randomized in a ratio of 1:1 to the PDA and control groups. Seventy-one patients completed the trial (control group, 36; PDA group, 35); this satisfied the sample size calculation. The median total Decisional Conflict Scale score in the PDA group was lower than in the control group (15.63 and 19.53, respectively). However, this difference was not statistically significant (difference between groups, 3.90; 95% confidence interval of the difference, -4.30 to 12.11). Sex, ethnicity, age, and the time point at which patients were recruited did not have significant effects on Decisional Conflict Scale scores. No harm was observed or reported for any participant in the study. CONCLUSIONS: The results of this study showed that the provision of a PDA to adolescents before they consented for fixed appliances did not significantly reduce decisional conflict. There may be a benefit in providing a PDA for some patients, but it is not yet possible to say how these patients could be identified. REGISTRATION: This trial was registered with the Harrow National Research Ethics Committee (reference 12/LO/0279). PROTOCOL: The protocol was not published before trial commencement.

Assessment of the effect of combined multimedia and verbal information vs verbal information alone on anxiety levels before bond-up in adolescent orthodontic patients: a single-center randomized controlled trial.

INTRODUCTION: Despite the high prevalence of dental anxiety in children, there is little research examining anxiety before orthodontic procedures. This parallel-group randomized controlled trial assessed whether provision of additional multimedia information regarding the bond-up procedure affected anxiety in adolescent orthodontic patients. The effects of sex, ethnicity, and age were also investigated. METHODS: Participants were recruited from the orthodontic department of the Eastman Dental Hospital, University College London Hospitals Foundation Trust, in the United Kingdom; all were 10 to 16 years of age, with no history of orthodontic treatment, and patient assent and parental consent were obtained. The participants were randomized into control (n = 45) and intervention (n = 45) groups using a random number table. Both groups were given verbal information regarding the bond-up procedure, and the intervention group was additionally given a DVD showing a bond-up. Anxiety was assessed in the department immediately before the bond-up using the State-Trait Anxiety Inventory for Children, with state anxiety as the primary outcome measure. The researchers were unaware of group allocations while enrolling patients, scoring questionnaires, and analyzing data. RESULTS: A statistically significant difference was found between groups, with a difference in scores of 2 (95% confidence interval for the difference = 0.15 to 3.85). The median state anxiety was 32 in the control group (n = 42) and 30 in the intervention group (n = 43; P = 0.012). Sex, ethnicity, and age did not significantly affect anxiety. No harmful effects were noted. CONCLUSIONS: Additional information reduces anxiety levels, but other methods could be more cost-effective than the DVD. Sex, ethnicity, and age did not statistically affect the anxiety levels.

Information-seeking behavior of adolescent orthodontic patients.

INTRODUCTION: Health-information-seeking behavior is the purposive search for health-related information. The literature contains few articles examining this behavior as it relates to orthodontics; therefore, the aim of this study was to investigate how adolescent orthodontic patients seek information about their treatment, why they search for this information, and how they prefer the information to be available. METHODS: In-depth interviews were conducted with 15 subjects, 10 to 16 years old, who were considering orthodontic treatment. The purpose of the interviews was to identify themes that were then used to develop a questionnaire to investigate information-seeking behavior. The questionnaire was distributed to 50 adolescent orthodontic patients. RESULTS: The main sources of information were talking to a dentist or an orthodontist (84%), talking to peers (66%), and reading information leaflets (64%). Surprisingly few respondents had used the Internet (8%). The preferred sources of information were talking to an orthodontist (26%) and family members (12%), followed by talking with the general dentist (10%), viewing a DVD (10%), or reading information leaflets (10%). CONCLUSIONS: The preferred method of obtaining information was verbal, followed by audiovisual and written. Audiovisual information could be beneficial for those who find reading difficult or who struggle to retain verbal information. Few patients accessed information via the Internet, and this was attributed to concerns about the reliability of the information.

Impact of dentofacial deformity and motivation for treatment: a qualitative study.

INTRODUCTION: Satisfaction with the outcome of orthognathic treatment is generally high; however, an important minority remains dissatisfied with the results. The reasons for this could be inadequate patient understanding and preparation, external motivation, and unrealistic expectations. In-depth appreciation of these issues can be obtained using qualitative research methods, but there is a paucity of qualitative research in this field. METHODS: This was a cross-sectional qualitative study of orthognathic patients conducted at a teaching hospital. In-depth interviews were conducted with 18 prospective orthognathic patients. The data were managed by using the framework approach and analyzed by using the critical qualitative theory. RESULTS: Two main themes were explored in the interviews: the impact of the dentofacial deformity and the motivation for treatment. Both the everyday problems of living with a dentofacial deformity and the motivation for seeking treatment could be classified either as exclusively practical (including functional and structural), exclusively psychological (including psychosocial and esthetic), or a combination. Different coping strategies were also described. The sources of motivation ranged between purely external to purely internal, with most subjects between these 2 extremes. CONCLUSIONS: In this article, we present a classification of the impact of dentofacial deformity that is a refinement of the traditional one that includes esthetic, functional, and psychosocial factors. The motivating factors, together with the triggers for accessing treatment and the source of motivation, are generally linked directly or indirectly to the problem and the impact of the condition. However, in a few patients, the motivation might not relate to the impact of the problem but to a complex array of other factors such as personality, upbringing, and relationships. Therefore, clinicians should not make assumptions but explore these factors on an individual basis without preconceived ideas.

What are orthognathic patients' expectations of treatment outcome--a qualitative study.

PURPOSE: Patient's expectations of treatment outcome are one of the key determinants of satisfaction. The aim of this study was to evaluate orthognathic patients' expectations of the outcome of orthognathic treatment. METHODS: This study was a cross-sectional qualitative study involving in-depth interviews with patients with dentofacial deformities. Patients who were about to commence orthognathic treatment were recruited from new-patient clinics. Inclusion criterion were patients of any ethnicity 16 years or older who were about to commence orthognathic treatment to correct a dentofacial deformity. Exclusion criteria were patients who had previously received orthognathic treatment, who were younger than 16 years, and those with congenital craniofacial anomalies or acquired defects. The data were analyzed using a framework approach to management and critical qualitative theory, which involved identifying the main themes and subthemes. RESULTS: Eighteen adult patients 18 to 40 years old were interviewed; 9 were women and 9 were men. Most were Caucasian and 6 were from the black and minority ethnic group. Participants' expectations could be divided broadly into 2 main categories: expectations of actual physical changes and expectations of the effects that these physical changes would indirectly have on them (nonphysical changes). In addition, a typology of patients, based on expectations, was identified, whereby patients could be classified as metamorphosizers, pragmatists, shedders, or evolvers, together with implications and suggestions for practice. CONCLUSIONS: These findings represent a new insight into the complex issues of managing patient expectations and satisfaction. The clinical relevance of identifying expectations is not just to ration treatment or identify those who will make good or bad candidates for treatment, but to be able to offer them additional support to enhance satisfaction with the outcome. This highlights the need for a qualitative methodology to complete the full circle of evidence-based practice.

The impact of altered sensation affecting the lower lip after orthognathic treatment.

PURPOSE: Inferior dental nerve paresthesia is a well-known risk of orthognathic surgery, but little is known about the effects of altered sensation in day-to-day life. Therefore the aim of this study was to assess the impact of altered sensation after orthognathic treatment. PATIENTS AND METHODS: The study was divided into 2 parts: the first phase involved semistructured, in-depth interviews with 13 post-treatment orthognathic patients who presented with altered sensation affecting the lower lip. In the second part of the study, the data from the interviews were used to develop a questionnaire that was distributed to 40 post-orthognathic patients (75% completion [n = 30]). The results were analyzed by use of descriptive statistical methods. RESULTS: In both stages of the study, common descriptors used to describe the altered sensation were "tingling" and "numb." The majority of patients were aware of the neurosensory disturbance when touching their lips, face, or jaw, and patients also expressed difficulties knowing when food was left on their lip. It was noted that patients who were aware of the altered sensation all of the time expressed the greatest distress in their everyday life. When it came to emotions associated with the altered sensation, the majority of patients were disappointed, but few were upset or angry. CONCLUSIONS: The impact of altered sensation due to inferior dental nerve damage after orthognathic surgery varied from patient to patient, but altered sensation had a significant effect on the majority of patients' everyday lives. The information obtained from this study makes an important contribution to the informed consent process.

Transmigration of a maxillary canine. A case report.

In the oral cavity, transmigration is defined as a tooth that crosses the mid-line by more than half its length. Following extensive literature review, it was found that, although well documented with respect to mandibular canines, there were only two publications detailing maxillary cuspid transmigration. This report presents a case of transmigration where the left maxillary canine gradually crossed the mid-line and migrated to the right side in a patient with hemifacial microsomia and cleft palate. The Mupparapu classification of the migratory pattern of the mandibular canines is discussed. Various clinical considerations, as well as guidelines for general practitioners to diagnose and manage such a condition, are also discussed.