From 1982 – 1987 Dr. Gerry Samson and Dr. Alan M. Gross studied various aspects of orthodontic patient compliance and non-compliance. Their research has been supported by the National Institute of Health, Division of Behavioral Medicine (Grant DEO 7978). Dr. Samson is dual trained in pediatric dentistry and orthodontics, is a diplomate of The American Board of Orthodontics (ABO), and is in the private practice of orthodontics and dentofacial orthopedics in Marietta, Georgia. Alan M. Gross, Ph.D. is Professor of Psychology, University of Mississippi. The following is a practical and clinical synopsis of Dr. Samson’s opinions based on research and clinical applications.
Diagnosis, prognosis, treatment plan and retention design have been brilliant. The clinician has an image of the successful end result, and it is time for corrective therapy to begin. Like a modern day Merlin, the orthodontist divines a headgear about the dentofacial alter, deftly places and activates the utility arch, and evokes an ectoplasmic image of Dr. Edward Hartley Angle. Confidently, the predicted treatment response is anticipated. For some, however, the “long lament” has begun. The case may be on the track of a compromised end result, or doomed to dismal failure. The patient may be non-compliant, and without compliance the brilliance of our magic will have a constipated and frustrating fate.
Intuitively, it seems reasonable to conclude that patient compliance/noncompliance exists along a continuum – that is, a patient may be cooperative concerning some aspects of treatment, and not cooperative with others. Although there are some data in the medical literature to suggest that patients are often selective concerning which aspects of their treatment program they will adhere to, no orthodontic studies had examined this issue.
The purpose of our study was to examine further the question of whether children are uniformly compliant/noncompliant or if they display distinct differences regarding the manner in which they respond to treatment instructions. Seventy-five children between the ages of 8 and 14 years of age were patients at a university orthodontic program, and served as subjects for the study.
Patients were rated on the level of success they displayed in three areas. Compliance with the use of “auxiliaries” (e.g. headgear and intraoral elastics), dietary restrictions (i.e., frequency of broken brackets, wires, and appliances), and adequacy of oral hygiene were all under our scrutiny. Independent ratings by a second orthodontist were obtained on all measures at approximately 15% of the assessments. Average interrater agreement exceeded 80% for each measure.
A multiple Pearson correlation was performed on the data. Significant correlations were observed between oral hygiene and broken brackets and appliances (r = -0.37, P<0.0001) and oral hygiene and use of auxiliaries (e.g. headgear) ( r = 0.23, P < 0.02). The relationships between the use of headgear and frequency of broken appliances was not significant. the orthodontists’ ratings of overall level of cooperation correlated with each measure of compliance (hygiene, r = 0.36, P ,0.001; broken appliances, r= -0.53, P < 0.0001: headgear, r = 0.42, P
< 0.0001). Since the data are correlational and not necessarily causal, caution must be exercised when interpreting these results. However, the data do show that children may be selective concerning which aspects of the orthodontic regime they will follow.
Gross and Samson (1985) have also suggested that orthodontic noncompliance be viewed as a discrete problem rather than a general behavior style. In the 1985 paper we, discussed the levels of predictability that might exist using a parents attitude of how compliant or noncompliant the patient might be. This also included a view of how well the patient was doing at school, and how well the patients themselves thought that they would might do during their headgear wear, dietary restrictions, and need for adequate oral hygiene. The parental ability to predict compliance, and how well a patient was doing at school were less than impressive in indicating orthodontic regime cooperation. Patient “self-perceptions” (global self-worth) were more significant.
The most substantial correlation, however, was found with the person treating the patient. That is, patients were most compliant with their treatment regimes when they “liked” the person treating them. The clinician should be aware, therefore, that a patient is far more likely to be compliant if that person has a positive opinion of the clinician. This compliant behavior may extend to parental responsibilities of office appointment times, keeping current with payment schedules, and parent/patient referrals to the practice.
Dr. Robert M. Ricketts has advised that the most important thing we do as clinicians is to motivate patients, and that motivation is an essential key to compliance and success that may take many forms.
It can be seen that the patient’s perception of the individual providing treatment to them is of paramount significance.
Gross, AM, Samson, GS, et. at.: Increasing Compliance With Orthodontic Treatment. Child & Family Beh. Ther. Vol 12 (2) 1990
Gross, AM, Samson, GS,: Patient Cooperation in Treatment with Removable Appliances: A Model of Patient Noncompliance with Treatment Implications. Am. Journ. Ortho., 87: 392 – 397, 1985
Gross, AM, Samson, GS,: Self-Concept and Cooperation with Orthodontic Instructions: A Re-Analysis. Jour. Pedo., Vol. 12, 128
– 134, 1988
Gross, AM, Samson, GS, et al; Patient Non-Compl;iance: Are Children Consistent? Am. Journ. Ortho.; 93, 518 – 519, 1988
By: Gerald S. Samson, DDS*