INTRODUCTION

Orthodontic treatment is a way of straightening or moving teeth, to improve the appearance of the teeth and how they work. Orthodontic treatment necessitates several disciplinary activities and restrictions such as attending appointments, daily practice of good oral hygiene, and dietary restrictions. Different samples of orthodontic appliances are used to correct malocclusion, retrain muscles, and effect on growth (Elhussein and Sandler, 2018).[1]

Psychological and behavioral aspects of patients play a significant role in non-adherence; it is crucial that patients must change their behavior and cooperate with clinicians/orthodontists to ensure positive outcomes of the treatment. The behavior of patients in the clinic is regarded as “compliance;” however, recently, it is termed as “adherence” (Tervonen et al., 2011).[2] Orthodontists believe that factors such as personality traits, motivation for treatment, maintenance of oral hygiene, and communication between orthodontist and patient contribute to adherence (Eppright et al., 2014; Schäfer et al., 2015; Zotti et al., 2016).[3-5] Poor adherence to orthodontic treatment leads a patient to several complications corresponding to decalcifications of the teeth, uncorrected malocclusion, negative psychological and social outcomes attributable to the appearance of their teeth and mouth, a prolonged course of treatment, premature treatment termination, wasted family and provider resources (Apajalahti and Peltola, 2007; Skidmore et al., 2006).[6,7] Adherence to orthodontic treatment is essential to ensure the patient’s ultimate positive treatment outcome; since it depends on timing and completion of the orthodontic treatment. However, the previous research demonstrated that data related to adherence to orthodontic treatment are not encouraging; since, treatment termination reported in 43–50% patients due to poor adherence to treatment (Mandall et al., 2008; Martin et al., 2017).[8,9]

It can be argued that non-adherence is not only related to attendance but also to several other factors. Since, poor adherence or non-adherence to the orthodontic treatment usually reflects in the form of poor oral hygiene, broken appliances, patients’ ability to cope with the experience of pain and discomfort during treatment, and non-compliance with wear of prescribed elastics or removable appliances (Crerand et al., 2019).[10] It can be argued that non-adherence to the orthodontic treatment is not uniform throughout all the situations; rather, it can be situational-based. Patients might exhibit adherence based on the anticipated outcome. In some instances, patients might be adherent; however, in other instances, they might be non-adherent. Patients might follow appointments on a regular basis; however, they might not wear the appliances during the treatment duration. Hence, clinicians should always be alerted to fluctuations and prepared to take corrective actions. Accurate predictions by the orthodontists regarding the adherence by patients are crucial in executing corrective strategy. Hence, it is essential to understand the orthodontist’s predictors regarding adherence (Al Shammary et al., 2017).[11] Further, these predictors can be implemented in a calibrated manner based on their importance for the measurement of patient adherence in the orthodontic setting. Several direct and indirect methods are available for estimating a patient’s adherence to the orthodontic setting. However, these methods are associated with limitations such as variable reliability and applicability due to variable orthodontic settings (Bos et al., 2007; Cole, 2002).[12,13]

The previous research demonstrated orthodontists’ interpretation of adherence of patients in the orthodontic setting which explored factors such as oral hygiene and appointment keeping as the indicators of adherence. However, these indicators cannot be generalized because these studies were conducted on the young population with a small number of participants. In the previous studies, either open- or closed-type questions were asked of the orthodontists (Bos et al., 2007; Al Shammary et al., 2015).[12,14] Moreover, studies evaluating orthodontist’s predictors of adherence to orthodontic treatment in Kingdom of Saudi Arabia (KSA) were not conducted.

This study aims to explore the predictors of orthodontists for adherence of adult patients in the orthodontic settings. Attention is given to rank these predictors in terms of importance and frequency of actual use, as stated by the orthodontist.

MATERIAL AND METHODS Type of study

This is a cross-sectional quantitative and exploratory survey to explore predictors of adherence which were informed in the previous research (Bos et al., 2007; Al Shammary et al., 2015).[12,14] Both open- and closed-ended questions are incorporated in this research.

Sample/participants

Attending level orthodontists, treating adult patients, in the KSA who could complete the survey in English were selected for participation in the study. On obtaining Institutional Review Board (IRB) approval (Reference No H-2020-004), participants were recruited by sending a short email. Participants were self-screened for eligibility. Participants were provided with the IRB-approved study information sheet detailing the benefits and risks of participation. Moreover, participants were informed about the anonymity and confidentiality of participation. The rights of human participation were protected, and study approval was taken from the Institutional Research Ethics Committee of Hail University. Participants were recruited through sending a short email. In accordance with Dillman, agreed details of the frequency of contact were sent to the orthodontists through email. For those participants with non-responsiveness, two subsequent emails were sent as reminders. Ninety-one orthodontists (48% of female and 52% of male) were recruited in this study. Participants with experience of more than 1 month (5%), 1–2 years (19%), 3–4 years (28%), and >5 years (48%) were recruited in this study.

Materials

The survey questionnaire developed for this study was constructed by the researchers. Questions were developed based on experience in the orthodontist setting and an extensive literature review related to orthodontic adherence. The survey questions were mainly divided into four sections, requesting participants to rate predictors of adherence: (1) Evaluation – how important they perceive the predictor was to measure patient adherence, (2) application – the level up to which they implemented each predictor to measure adherence in their daily practice, (3) open-ended questions to amass adherence predictors which they understood were worth and were also requested to rate them with respect to their importance and frequency of use, and (4) demographics, including gender and years in practice with adults. The questions in section 1 were answered on a five-point Likert scale (with 1 rated as not at all important and 5 rated as extremely important). The questions in section 2 were responded on a five-point Likert scale (with 1 rated as predictor with never applicable for adherence and 5 rated as predictor which is always applicable in daily practice). In part 3, participants were invited to answer the open-ended questions to propose other predictors of adherence. Moreover, orthodontists were requested to rate these predictors based on the importance and applicability on a five-point Likert scale. The overall scale was found to be highly reliable (24 items; alpha 5.83), whereas Cronbach’s alphas for the 12 important and 12 use items were 0.5 and 0.87, respectively.

Data analysis

Descriptive analysis in terms of frequencies, central tendency, and dispersion measures was performed for each of the questions in the list, and two scales that are based on importance and frequency (applicability). Additional predictors that emerged from the open-ended questions were coded and organized under individual categories, and a similar descriptive analysis was reported. Further, a descriptive analysis of two scales was performed that comprise a whole list of predictors from the original list and those added from the participants.

RESULTS Predictors based on important while assessment of adherence in adult patients

Participants rated 12 factors on the five-point Likert scale. Higher importance to the factor is reported in terms of higher scores. The mean and standard deviation (SD) of each factor are shown in [Table 1].

Table 1: Mean Importance Ratings for Each Factor.

Sr. No Factor Frequency of responses (%) Extremely unimportant Very unimportant Neither unimportant nor important Very important Extremely important Mean SD 1 The patient keeps appointments 6.00 (3) 30.00 (15) 64.00 (32) 4.58 0.61 2 The patient is pleasant to the clinic staff 6.12 (3) 22.45 (11) 42.86 (21) 28.57 (14) 3.91 0.89 3 The patient has distorted or damaged wires and/or loose bands 12.24 (6) 42.86 (21) 46.94 (23) 4.37 0.66 4 The patient is observed to be involved in treatment. 4.17 (2) 16.67 (8) 45.83 (22) 35.42 (17) 4.11 0.82 5 The patient speaks of personal problems or demonstrates such problems 6.25 (3) 25.00 (12) 33.33 (16) 25.00 (12) 12.50 (6) 3.14 1.08 6 The patient is observed to be enthusiastic about treatment 2.08 (1) 14.58 (7) 43.75 (21) 39.58 (19) 4.22 0.76 7 The patient cooperates with the use of removable dental appliances (such as retainers) and/or elastics. 2.08 (1) 4.17 (2) 20.83 (10) 72.92 (35) 4.63 0.75 8 The patient complains about treatment procedures (i.e., procedures performed by the orthodontist) 10.42 (5) 27.08 (13) 54.17 (26) 10.42 (5) 3.65 0.78 9 The patient maintains excellent oral hygiene. 4.17 (2) 14.58 (7) 81.25 (39) 4.77 0.51 10 The patient complains about having to wear braces 2.08 (1) 6.25 (3) 25.00 (12) 50.00 (24) 16.67 (8) 3.74 0.88 11 The patient has a negative view or perception of their malocclusion 12.50 (6) 25.00 (12) 50.00 (24) 12.50 (6) 3.64 0.86 12 The patient thinks that facial esthetics are important 2.04 (1) 22.45 (11) 51.02 (25) 28.57 (14) 4.05 0.76

The cutoff score was fixed at 4.5 out of 5. Based on this cutoff score, the following were the three factors with the highest importance, “The patient maintains excellent oral hygiene (score 4.77),” “The patient cooperates with the use of removable dental appliances (such as retainers) and/or elastics (score 4.63),” and “The patient keeps appointments (score 4.58).” The factor with the lowest score was “The patient speaks of personal problems or demonstrates such problems (score 3.14).” From the results, it can be argued that most of the factors scored intermediate scores; these are neither on the higher side nor the lower side. It is likely; since most of the orthodontists did not rate these factors as either extremely important or extremely unimportant.

The factors with the highest rating were also not rated in a uniform manner by all the participants. Few of the participant’s ratings demonstrated deviation from the majority of the participant’s ratings for highly scored factors. About 4%, 4%, and 6% of participants rated “Neither Unimportant nor Important” for factors such as “The patient maintains excellent oral hygiene,” “The patient cooperates with the use of removable dental appliances (such as retainers) and/or elastics,” and “The patient keeps appointments,” respectively. However, it can be argued that the number of participants with a rating “Neither Unimportant nor Important” was very low. None of the participants rated “Very Unimportant” or “Extremely Unimportant” for factors that scored above 4.5. However, participants demonstrated varied responses to the factor with the lowest score, “The patient speaks of personal problems or demonstrates such problems;” since 12% of the participants rated this factor as extremely important. Predictors based on frequency of use while assessing adherence of adult patients in their daily practice

Participants rated 12 factors on the five-point Likert scale. High score indicates a high frequency of use and low score indicates a low frequency of use. The mean and SD of each factor are shown in [Table 2].

Table 2: Mean and SD frequency of use of each factor.

Sr. No. Factor Frequency of Use (%) Never Rarely Some times Most of the time Always Mean SD 1 The patient keeps appointments 5.71 (2) 62.86 (22) 34.29 (12) 4.31 0.53 2 The patient is pleasant to the clinic staff 2.86 (1) 5.71 (2) 20.00 (7) 51.43 (18) 28.57 (10) 4.11 0.71 3 The patient has distorted or damaged wires and/or loose bands 22.86 (8) 31.43 (11) 25.71 (9) 22.86 (8) 3.51 1.05 4 The patient is observed to be involved in treatment. 2.86 (1) 22.86 (8) 34.29 (12) 42.86 (15) 4.16 0.84 5 The patient speaks of personal problems or demonstrates such problems 2.86 (1) 25.71 (9) 34.29 (12) 20.00 (7) 22.86 (8) 3.38 1.12 6 The patient is observed to be enthusiastic about treatment 2.86 (1) 8.57 (3) 71.43 (25) 20.00 (7) 4.1 0.56 7 The patient cooperates with the use of removable dental appliances (such as retainers) and/or elastics. 11.43 (4) 25.71 (9) 37.14 (13) 28.57 (10) 3.83 0.95 8 The patient complains about treatment procedures (i.e., procedures performed by the orthodontist) 2.86 (1) 25.71 (9) 37.14 (13) 22.86 (8) 17.14 (6) 3.3 1.06 9 The patient maintains excellent oral hygiene 2.86 (1) 8.57 (3) 34.29 (12) 28.57 (10) 34.29 (12) 3.85 0.99 10 The patient complains about having to wear braces 2.86 (1) 28.57 (10) 42.86 (15) 22.86 (8) 8.57 (3) 3.08 0.94 11 The patient has a negative view or perception of their malocclusion. 5.71 (2) 8.57 (3) 48.57 (17) 34.29 (12) 8.57 (3) 3.38 0.83 12 The patient thinks that facial esthetics are important 5.71 (2) 11.43 (4) 31.43 (11) 25.71 (9) 28.57 (10) 3.63 1.10

None of the factors demonstrated a score above the cutoff value (4.5). Hence, factors with a score of more than 4 were considered as high scoring. Four factors were rated with high frequency such as “The patient keeps appointments (score 4.36),” “The patient is observed to be involved in treatment (score 4.16),” “The patient is pleasant to the clinic staff (score 4.11),” and “The patient is observed to be enthusiastic about treatment (score 4.10).” Four factors were rated below the lower cutoff value of 3.5 such as “The patient speaks of personal problems or demonstrates such problems (score 3.38),” “The patient has a negative view or perception of their malocclusion (score 3.38),” “The patient complains about treatment procedures (i.e., procedures performed by the orthodontist) (score 3.3),” and “The patient complains about having to wear braces (score 3.08).” Even though four factors were rated with high frequency, there was no agreement among all the participants. For the factor, “The patient keeps appointments,” around 5% of participants rated it sometimes. Moreover, participants rated rarely and never for factors,

“The patient is observed to be involved in treatment (rarely 3%),” “The patient is pleasant to the clinic staff (rarely 6% and never 3%),” and “The patient is observed to be enthusiastic about treatment (never 3%).”

Predictors based on open-ended questions

Orthodontists expressed factors such as oral hygiene, cost, patient-related factors, time, integrative and cooperative approach in treatment, and other factors, in relation to the adherence in the orthodontic setting factor are presented in [Table 3]. The most important identified factors for adherence, according to orthodontists, were “oral hygiene” (M = 4.5; SD = 1.0), “integrative and cooperative approach in treatment,” (M = 4.5; SD = 0.5) and “other factors” (M = 4.5; SD = 1.1). Least important identified factor for adherence, according to orthodontists, was, “time” (M = 3.8; SD = 1.0). The most frequently used factors used by orthodontists to asses “adherence were oral hygiene” (M = 4.3; SD = 1.0) and “patient-related factors” (M = 4.3; SD = 1.0). Less frequently employed factor by orthodontists was “time” (M = 3.5; SD = 0.6).

Table 3: Mean and SD of group of adherence factors which were newly added by the orthodontists.

Adherence Factors Importance Frequency Mean SD Mean SD Oral hygiene (4) 4.5 1 4.3 1   Oral hygiene   Maintaining Oral Hygiene from the patient   Oral hygiene   Oral hygiene Cost (3) 4.3 0.6 4 1   Cost   Cost   The price of adjustment Patient related factors (7) 4.4 0.5 4.3 1   Internal motivation   Showing in clinic on emergencies   Treatment progress   Educating the patient about his malocclusion and treatment options   Interest of the patient in the treatment   Transportation to the clinic for female patients   Calling to ask about abnormalities with teeth during treatment Time (4) 3.8 1.0 3.5 0.6   Time of treatment available in the clinic no evening time   Time   Tolerance to long treatment duration 2 years   Continuing the treatment Integrative and cooperative approach in treatment (8) 4.5 0.5 3.8 1.4   Trusting the orthodontist   Cooperation of the patient   Willing to change the Treatment plan if necessary   Relation with there orthodontist   Involving patient in their treatment objectives   Good contact between patient and doctor   Friendly environment   Going by the rules Other factors (8) 4.5 1.1 3.9 1.2   Accepting new modules to help achieving good results such as mini-implants, forces, etc   Visibility of brackets some prefer none bracket or lingual   Damage   Clean of the clinic   Realistic expectations   Proper sterilization   Behavior   Being professional DISCUSSION

In this study, a survey was conducted to understand adherence predictors in orthodontic settings in terms of its importance and frequency of use in daily practice. In addition to these question-based factors, other relevant factors were extracted through presenting open-ended questions to the participants.

The majority (71%) of the orthodontists reported treatment termination in <10% of cases and 29% of orthodontists reported treatment termination in 11–30% of patients due to poor adherence to the treatment (Crerand et al., 2019).[10] Mehra et al. (1998)[15] reported that 95% of orthodontists reported treatment termination in <5% of the patients, while 5% of orthodontists reported treatment termination in 5–10% of the patients. Adherence to treatment is a crucial factor in cases of prolonged treatment. However, there is no consensus to define prolonged treatment in an orthodontic setting. In some cases, minimum 3 months of treatment and in a few cases, 1-year treatment, beyond the agreed on end of treatment is considered as prolonged treatment. Research demonstrated that family domain and health-care system factors also significantly influence adherence. In the family domain, factors such as family members’ mental health, treatment motivation, supervision of care by the family members, coping skills, and awareness of the treatment plan have a substantial impact on adherence. Hence, it is essential to target interventions to family members’ motivation and behavior. Motivation by family members can be exemplified by monitoring oral hygiene of patients by the family members. Health-care system-related factors include communication between the patient and health-care providers which promotes change in the behavior of patient and the family members. Health-care system-related factor targets orthodontic education program and dietary instructions (Wysocka et al., 2014; Crerand et al., 2019).[16,10]

In the present study, three factors were rated with the highest importance which includes, “The patient maintains excellent oral hygiene,” “The patient cooperates with the use of removable dental appliances (such as retainers) and/or elastics,” and “The patient keeps appointments.” However, a minimal number of participants did not give importance to these factors. These insignificant numbers of participants would not affect the outcome of the study; however, it is worthwhile to assess the reason behind not giving importance to these factors by these small number of participants. It is obligatory that orthodontists should practice the factors of adherence to which they give more importance. However, in actual practice, these orthodontists practice only one factor, “The patient keeps appointments.” It can be argued that participants gave the least importance to this factor out of the three factors with more importance. Nevertheless, orthodontists implemented this factor more frequently in comparison to any other factor. From the obtained results, it can be argued that there was partial agreement between the importance and practice of orthodontists in assessing patient adherence. Orthodontists practiced only one factor in assessing patient adherence; though, the other two factors are also deemed important. Some of the findings from this study were consistent with factors reported in the previous studies. Mehra et al. (1998) and Slakter et al., (1980)[15,17] reported factors such as maintaining regular appointments, good oral hygiene, and adequate use of appliances, as relevant factors for the adherence of patients in orthodontic settings.

For few of the factors studied in this study, there was no agreement between the level of importance and its implementation in actual clinical practice. For factors such as “The patient has distorted or damaged wires and/or loose bands” and “The patient maintains excellent oral hygiene,” orthodontists mentioned neither “Not so important” nor “Not at all important.” However, a realistic number of participants employed it rarely in actual practice. Orthodontists demonstrated a positive correlation among factors with the lowest importance and least employed in the actual practice. Orthodontists demonstrated the lowest scores in terms of both importance and frequency for factors such as, “The patient speaks of personal problems or demonstrates such problems,” “The patient complains about treatment procedures (i.e., procedures performed by the orthodontist),” “The patient complains about having to wear braces,” and “The patient has a negative view or perception of their malocclusion.” It reflects, orthodontists are not willing to implement the adherence factor in actual practice, if they do not feel it as important factor. Out of these four factors, Slakter et al. (1980),[17] stated “The patient speaks of personal problems or demonstrates such problems” as adequate measure of adherence in orthodontic setting.

Through open-ended questions, different predictors of adherence were explored, which include oral hygiene, cost, patient-related factors, time, and integrative and cooperative approach in treatment. These predictors comprise different factors which were coded under respective predictors. Among these, “oral hygiene” and “integrative and cooperative approach in treatment” were stated as the most important factors by the orthodontists. Moreover, “oral hygiene” and “patient-related factors” were more frequently employed adherence measures by the orthodontists. There was not much difference between “oral hygiene” and “patient-related factors” in terms of its importance. Hence, these two factors can be considered as most acceptable predictors stated by the orthodontists through the open-ended questions. The previous research also demonstrated that “oral hygiene” and “keeping appointments” are most important predictors for patient adherence; however, these were not most frequently used by the orthodontists (Martin et al., 2005; Brattström et al., 1991).[18,19] However, authors argued that the lack of evidence for the frequent use of these predictors might be due to improper record keeping of these predictors during actual practice. Most of the predictors reported during open questions were stated for the 1st time in adult’s orthodontic setting. Hence, its importance and frequency of use should be revalidated in a study comprising structured questions.

Limitations

The current study lacks patient-reported data. It would be advisable to integrate the data obtained from the orthodontists with the data obtained from the patients to ensure the validity of the outcome. Orthodontists responded differently for the same predictor which might be due to different working environments or hospital settings for the orthodontists. Hence, to assess an accurate measure of adherence, it would be advisable to conduct a study of orthodontists from a similar type of hospital setting. In a similar fashion to other studies which include non-probabilistic samples, this study also offers an opportunity for further research. It would be advisable to validate the outcome of this study in a randomly selected larger population.

CONCLUSION

“The patient maintains excellent oral hygiene” was regarded as the most important predictor by the orthodontists. “The patient keeps appointments” was regarded as the most frequently used predictor by orthodontists. In open-ended questions, orthodontists highlighted “Oral hygiene” and “Integrative and cooperative approach in treatment” as the most important predictors for adherence in an orthodontic setting. Furthermore, “Oral hygiene” and “Patient-related factors” were reported as the most frequently used predictors through the open-ended questions.