<%BANNER%>

Orthodontic Psychosocial Impacts


PAGE 1

ORTHODONTIC PSYCHOSOCIAL IMPACTS By BRETT THOMAS LAWTON A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2003

PAGE 2

ii ACKNOWLEDGMENTS To my family, Mother and Father, and Li sa, I am grateful for their help and support. My accomplishments would not have been possible without their love and patience over the years. To my wife, Laura, and daughter, Annabell e, I am very grateful for the patience and support they have provided me throughout the many years of training. I look forward to our lifetime of happiness. To my committee—Drs. Wheeler, Dolan, Dol ce, and McGorray—I appreciate their dedication to me and insuring success throughout my training. I sincerely respect each of them and their commitment to research and academic excellence.

PAGE 3

iii TABLE OF CONTENTS Page ACKNOWLEDGMENTS...............................................................................................ii ABSTRACT....................................................................................................................iv INTRODUCTION............................................................................................................1 MATERIALS AND METHODS......................................................................................4 RESULTS........................................................................................................................ .8 DISCUSSION.................................................................................................................12 CONCLUSIONS.............................................................................................................16 APPENDIX. EXAMPLE OF SURVEY ADMINISTERED AT EACH DATA COLLECTION TIME POINT..................................................................................17 REFERENCES...............................................................................................................19 BIOGRAPHICAL SKETCH..........................................................................................21

PAGE 4

iv Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science ORTHODONTIC PSYCHOSOCIAL IMPACTS By Brett Thomas Lawton May 2003 Chair: Timothy T. Wheeler Major Department: Orthodontics The treatment impacts experienced by pa tients undergoing different orthodontic treatment modalities are e ssentially unknown. With the advent of contemporary techniques such as Invisalign this information may prove to be influential for both the patient and practitioner. As a component of an ongoing prospective clinical trial we assessed the psychosocial impacts of orthodontic treatment on 37 patient s with traditional edgewise appliances in comparison to one hundred patients under going treatment with Invisalign Impacts were assessed using a modifi ed General Oral Health Assessment Index (GOHAI). Participants completed survey s at pretreatment baseline, 3, 6, 12, and 18 months and at the completion of treatment. The treatment groups were comparable in terms of age, sex, race, marital status, and pr evious orthodontic treatment. However, the Invisalign group showed higher levels of educ ation and income (p=0.02), which may influence the reports of treatment impact There were limited differences in the experience patients undergo regardless of whic h treatment method is used. One exception was that Invisalign patients reported more impacts at 6 months in comparison to

PAGE 5

v edgewise patients (p=0.02). However, this difference was not appr eciable at any other time. Overall, the two treatment groups reported similar treatment impacts, with few differences by treatment method.

PAGE 6

1 INTRODUCTION The psychosocial impacts of orthodontic treatment on patients have not been well studied. Better understanding of treatment imp acts including pain, discomfort, difficulty chewing, eating or swallowing or interference with daily activities could facilitate patient expectations during treatment. Moreover, as new techniques are introduced to the orthodontic armamentarium, it is crucial that both parties are aware of key differences that exist specific to the propo sed means of treatment. Medical and dental practitioners are expe riencing a radical transformation from the traditional, intuitive, unsystema tic and paternalistic ideolo gy of providing care to one respecting evidence-based, patient-centered outcomes (Fernandes et al., 1999). A dichotomy of information now exists between (1) the clinician fo rmulating a rational, objective means for treatment, an d (2) the consumer perspective and subjective information one regards as integral to a successful outcome (Vig et al., 1999). Whereas the foundation for bridging communication be tween patient and provider has been established, a significant divide still exists which hinders each party’s ability to express more subjective emotions including satisfaction and expectations. The satisfaction a patient feels towards tr eatment is often difficult to define and assess. In the simplest of terms, satisfaction may be understood as fulfillment one receives resulting from an event or service (Miller, 1977). A more contempora ry definition states that treatment satisfaction amou nts to the difference between what the patient expects and what the patient receives (Vig et al., 1999; Day, 1977). A more philosophical

PAGE 7

2 understanding of treatment satisfaction involv es the individual’s perceived value of services provided and the resultant behavior they express as a resu lt (Linder-Pelz 1982; Vig et al., 1999). Contemporary medicine and dentistry have been subject to an emerging trend of analyzing patient satisfaction. It is clear that this term satisfaction is rather broad in scope, composed of many unique aspects that combin e to portray a sense of satisfaction with treatment. Such factors include well studied ideas including happiness with providers, opinion of treatment results, and convenience of care provided. However, psychosocial impacts including pain, discomfort, difficul ty in chewing and interference of social interaction have not been analyzed. Patie nts undergoing orthodontic treatment may experience significant psychosocial impacts including the inability to speak clearly, eat efficiently, sleep or relax, smile without embarrassment, or maintain their normal emotional, social or busine ss roles and responsibilities. There is little literature concerning patient experience and attitude towards orthodontic therapy (Lew, 1993). Cu rrent quality of lif e measures developed for dentistry are commonly inapplicable to assess such interactions in orthodon tics (O’Brien et al., 1998) given the lack of a diseased state of oral health and th e elective nature of cosmetic treatment. Furthermore, extended dura tion of orthodontic treatment and cyclic, intermittent discomfort associated with activat ion of appliances establish the experience patients undergo to be unique. The orthodont ic patient population, their motivation and their expectations for a pleasing outcome are key factors that must be considered to accurately report patient satisfa ction with the orthodontic experience. It then becomes

PAGE 8

3 necessary to further our unders tanding of the subjective pe rceptions patients experience while undergoing orthodontic treatment. The Department of Orthodontics at the University of Florida was commissioned to execute a prospective clin ical trial of 100 Invisalign pa tients to analyze a number of factors. We felt the psychosocial impacts asso ciated with various orthodontic treatment modalities were in need of further study. T hus, the opportunity to compare these impacts between subjects undergoing edgewise or Invisalign treatment was available and convenient for study. This pilot study was designed to capture the self-reported impacts both populations experience in hopes that we may more clearly understand how influential differing modalities of tr eatment affect orthodontic patients.

PAGE 9

4 MATERIALS AND METHODS A prospective, longitudinal study was c onducted to compare the influences that orthodontic treatment had on patients with traditio nal edgewise appliances in comparison to others undergoing treatment with Invisalign in a current clinical tr ial. All subjects were treated in the resident, faculty or research orth odontic clinics at the Un iversity of Florida, College of Dentistry in Gainesv ille, Florida. Subjects were at least 18 years of age, willing to sign informed consent, in good health, and able to be treated without extractions excluding a single lower incisor or third molars. The institutiona l review board for research at the University of Florida approved th e protocol prior to beginning the study. One hundred Invisalign and thirty-seven edgewise patients were recruited to participate in the study. Five Invisalign and three edgewise patie nts dropped out of the study for a final sample of 95 and 34 patie nts, respectively. Unique identification numbers were assigned to each patient. The sa mple consisted of 85 females and 44 males, and a mean age of 29.1 years ranging from18 to 58 years. The surveys administered [see append ix] were a compilation of previously described methods used in the general oral health assessment index (GOHAI), the Rand Health Insurance study (RHIS) and contem porary work by Locker (1997). The GOHA index is regarded as a valid means in relati ng psychosocial effects of one’s oral health condition without the presence of a disease state (Atchison, 1997; Atchison and Dolan, 1990). This index was designed to evaluate three aspects of oral health status : 1) physical function (i.e. eating, speech, a nd swallowing); 2) psychosoc ial function (anxiety, concern

PAGE 10

5 about oral health, withdraw from social interactions secondary to oral health status); and 3) pain or discomfort of the oral cavity. The RHIS study aimed to quantify the amount of pain, worry and concern with social interactions secondary to diseased oral health status. Locker modified these methods by recording no minal and ordinal responses pertaining to subjects’ ability to function in specific cases such as chewing firm meat, or eating an apple. The compilation of these three indices resulted in the four questions that were asked as a part of the survey. The fifth question was open ended and allowed for any additional input the patient desi red to share with the research er in regards to their oral health status. Participants completed identical surveys at baseline/pre-treatment, 3-, 6-, 12and 18 months and at the end of treatment [see a ppendix]. Surveys were administered at the beginning of each visit corresponding to th e data collection ti me point. Subjects completed the survey based on their experi ence since their last orthodontic visit. Demographic data was also collecte d from both samples [Table 1]. All responses were recorded in an or dinal manner with one open-ended question for patients to make additional notes if nece ssary. The ordinal responses from each of the four questions were summed and compare d. The mean and median values for each population were then compared. Figures 2-5 gr aphically represent the recorded responses for each question over the aforementioned time points. The demographic and survey data were evaluated by means of Wilcoxon Rank Sum and two-sample t-tests. Spearman correlation coefficients were used to evalua te similarities between the two populations.

PAGE 11

6 Table 1: Summary of Demographic Data Invisalign Edgewise Age Mean Age in years 30.6 27.5 Standard Deviation 9.54 9.09 Minimum 18.1 18.8 Maximum 56.4 58.4 Education Level
PAGE 12

7 RESULTS A significant number of baseline differe nces were detected between the two populations in question [Figures 1-4]. Ques tions 1, 3 and 4 indi cate the Inivisalign sample began treatment with less dental impacts than the edgewise group, although significant changes were appreciable throughout the course of treatment. Because of the baseline differences, we adjusted the data to reflect the changes from each group’s baseline to more accurately reflect the imp act change over time. When comparing each population’s change from base line, it appears the Invi salign population is more negatively impacted at 6 months than the e dgewise sample (p=0 .0253). However, this relationship appeared transient and was not demonstrated at the following data collection time point of one year. Positive correlations in both samples indicate consistent relationships in the survey responses [Table 2], although no signi ficant correlation existed within the edgewise group between survey [s ee appendix] questions 2 and 4 (r2 = 0.08, p=0.12) and questions 3 and 4 (r2 = 0.08, p=0.10). Given these correlatio ns, the applied survey appears to elicit similar relationships each sample group recorded. Demographic information [Table 1] showed similarities in both sample groups. The study population consisted of appr oximately twice as many women (n=85) as compared to men (n=44), at least 50% w ith college degrees, and approximately 2/3 receiving previous orthodon tic treatment. The Invisa lign population reported a significantly higher annual income (p=0.0234) [Figure 5] and had more education,

PAGE 13

8 although this finding was not st atistically significant (p=0.07 ). The edgewise group was composed of more current students than Invi salign (p=0.052). No significant differences were appreciable between groups in marital st atus, age, sex, race or history of previous orthodontic treatment. Question 1 46 47 48 49 50 51 52 53 54 Baseline3 months6 months12 months TimepointMean Recorded Value Invisalign Edgewise Figure 1: Mean recorded values from survey question 1 for time points baseline through 12 months. Significant baseline differences appreciable between groups. Invisalign started off higher (better), and tends to report more positive findings over time. Edgewise group is si gnificantly lower at baseline and 3 months, equal at 6 months, and slightly lower at 12 months. Slight upward trend a ppreciable for both samples.

PAGE 14

9 Question 2 20 21 22 23 24 25 26 Baseline3 months6 months12 months TimepointMean Recorded Value Invisalign Edgewise Figure 2: Mean recorded values from survey question 2 for time points baseline through 12. months. No significant differences appreciable in th e societal and professional impacts between treatment groups. Question 3 24 25 26 27 28 29 30 Baseline3 months6 months12 monthsTimepointMean Recorded Value Invisalign Edgewise Figure 3: Mean recorded values from survey question 3 for time points baseline through 12 months. Higher recorded value indicates less impact on eating and speaking. Similar differences reported over time. Invisalign tends to report more positive findings over time.

PAGE 15

10 Question 4 0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 Baseline3 months6 months12 monthsTimepointMean Recorded Value Invisalign Edgewise Figure 4: Higher recorded value indicates less pain. Significant baseline differences indicate Invisalign sample had less baseline dental discom fort. Demonstrates minimal negative impact upon reported pain levels overall.

PAGE 16

11 Income Differences0 10 20 30 40< 10K 1 0-25 K 25-50K 50-75K 751 00 K >10 0 KAnnual IncomePercentage Invisalign Edgewise Figure 5: Reported annual income of the study group. Table 2: Spearman correlation coefficients for each population. Positive correlation indicates similarity in responses within and between groups. All correlations were significant except for questions 2 and 4 and questions 3 a nd 4 for the edgewise group. Invisalign Correlations Question 2 Question 3 Question 4 Question 1 r=0.27 p=0.009* r=0.51 p<0.001* r=0.23 p=0.0246* Question 2 r=0.25 p=0.0131* r=0.35 p=0.0005* Question 3 r=0.36 p=0.0003* Edgewise Correlations Question 2 Question 3 Question 4 Question 1 r=0.37 p=0.046* r=0.48 p=0.0068* r=0.6 p=0.0004* Question 2 r=0.5 p=0.004* r=0.29 p=0.12 Question 3 r=0.29 p=0.10

PAGE 17

12 DISCUSSION The results of this study regarding th e psychosocial impacts of orthodontic care are inconclusive. Few significant differences between sample groups are appreciable. Moreover, there were significant baseline di fferences that make comparison of each group difficult and perhaps misleading. To adjust for baseline differences, we compared the difference each sample group experienced since baseline. The one significant difference observed between the edgewise and Invisalign group at 6 months was transient and not appreciable at the followi ng data collection time point of 12 months. No clear explanation is av ailable to justify this finding. One may speculate the edgewise patients may have experienced the majority of discomfort early on, and now appreciate the results as their chief complain t has been resolved. It is possible that the Invisalign sample may be dissatisfied in the progress at this time, especially if the aligners are not fitting corre ctly, if they require extens ive interproximal reduction, or perhaps requiring their case to be rebooted due to inconsistencies. Why this concern is not appreciable at on e year is unfounded. When analyzing the results for each question, several interesting points are noteworthy. Question 1 elicited a more posit ive response from Invisalign patients over time, although both sample groups demons trate a slight upward trend. Question 2 demonstrated very little difference in the societal and functional impacts each sample experienced. This finding suggests that ort hodontic treatment regardless of modality has little, if any, impact on patients’ professional ro les and social responsibilities. Question 3

PAGE 18

13 addresses similar concerns to que stion 1 in regards to the imp act on patients’ ability to eat or speak effectively. Invisalign patients repo rted significantly more positive findings over time indicating less impact from treatment. Qu estion 4 addressed the level of pain or discomfort for each population. A significant baseline difference was noted as edgewise patients elicited responses sugge stive of more dental pain in comparison to the Invisalign sample. This difference in reported discomfort was not significant at other time points. The study population was unique for several reasons in comparison to the typical adolescent population that dom inates most orthodontic pr actices. Approximately three times as many adult women elect to receive treatment compared to men (Nattras et al., 1995), and whom at least half have received a college education (Sergl and Zentner, 1997; Kiyak et al., 1985). Approximately 20% (McKiernan et al., 1992) to 50% (Sergl and Zentner, 1997) have undergone previous orthodontic treatment. The increase in the number of adults seeking orthodontic treatment has been attributed to a number of possible factor s, including increased public awareness, increased preoccupation with health and a ppearance, the increased availability of resources, and expanded demand for orthodont ic support to other dental specialties (McKiernan et al., 1992). In addition, Breece and Nieberg have reported a general increase in social acceptability of app liance therapy (Breece and Nieberg, 1986). Technologic advances have played a significant role in this phenomenon with the advent of long-duration memory wires, low profile or ceramic brackets (K uhlberg et al., 1997), and contemporary treatment modalities, such as Invisalign (Nattrass et al., 1995) The data in this study suggest limited differences in treatment impacts exist between the Invisalign or edgewise populati ons. Literature in support of this finding

PAGE 19

14 suggests adults may be less influenced by their peer perceptions, and are more stable in their concerns about appearance compared to adolescents (Stenvik et al., 1996). Indeed, many authors recognize the desire for impr ovement as a sign of ego strength not weakness (Kiyak et al., 1984; Proffit, 1993). Th e preliminary data from this pilot study may suggest adults do not appreciate a significant difference in how Invisalign or edgewise appliances influence their lives, but moreover how orthodontic treatment in general affects them. Several potential weakne sses to this study are worthy of mention. Feine and colleagues (Feine et al., 1998) reported pa tients cannot accurately recall differing intensities of pain over time, and the perceive d discomfort greatly depends on the level of pain before treatment. The literature suggests the discomfort these subjects reported is not accurate given the retrospective nature in which they were polled, and the extended duration of time between data collection tim e points ranging from one to 6 months. Furthermore, subjects were polled to record the treatment impacts since their last visit, which may be highly variable and deceiving for each patient. It is likely that key differences exist between the two sample s immediately following the initiation of treatment or shortly after a change in wire s or aligners. As a result of these unknown variables, a study to record these differences by means of a similar survey administered daily for one week immediately following th e first day of active treatment has been started. Several weaknesses existed in the sample populations for this study. The Invisalign population was concurrently invol ved in an ongoing university study analyzing a multitude of factors in addition to this survey. Variations in treatment

PAGE 20

15 requirements, mechanics and protocols asso ciated with such a clinical trial may compound the variability in this data, and ma y not be reflective of the experience in private practice. The sample size difference is significant between the two populations studied. The edgewise population was limited pr imarily due to the lack of adult patients meeting the inclusion criteria in the univers ity setting. Lastly, the significant differences at baseline limit the ability to draw firm conclusions regarding the difference in impacts experienced by each sample group. Further study of patient satisfact ion in the private sector has been initiated to evaluate these potential differences.

PAGE 21

16 CONCLUSIONS Although this study did not demonstrate any appreciable differences in treatment impacts between edgewise and Invisalign patients, further study is indicated. Orthodontists should be concerned for the sa tisfaction of patients and the impacts of treatment. Likewise, the success of patient treatment and the speci alty of orthodontics demand a better understanding of the emotional and functional transformations incurred in orthodontics. Such information will certainly be of great benefit to both the patient and the practitioner.

PAGE 22

17 APPENDIX EXAMPLE OF SURVEY ADMINISTERED AT EACH DATA COLLECTION TIME POINT 1. Please circle one response for ea ch of the following questions. In the past month, how often: Always Often Sometimes Seldom Never a. did you limit the kinds or amounts of food you eat because of problems with your mouth or teeth? 1 2 3 4 5 b. did you have trouble biting or chewing any kinds of food, such as firm meat or apples? 1 2 3 4 5 c. were you able to swallow comfortably? 1 2 3 4 5 d. did your teeth prevent you from speaking the way you wanted? 1 2 3 4 5 e. were you able to eat anything without feeling discomfort? 1 2 3 4 5 f. did you limit contact w ith people because of the condition of your mouth or teeth? 1 2 3 4 5 g. were you pleased or happy with the looks of your mouth or teeth? 1 2 3 4 5 h. did you use medication to relieve pain or discomfort from around your mouth? 1 2 3 4 5 i. were you worried or concerned about the problems with your mouth or teeth? 1 2 3 4 5 j. did you feel nervous or self-conscious because of problems with your mouth or teeth? 1 2 3 4 5 k. did you feel uncomfortable eating in front of people because of problems with your mouth or teeth? 1 2 3 4 5 l. were your teeth sensitive to hot, cold, or sweets? 1 2 3 4 5 2. During the past month, how often has pain, discomfort, or other problems w ith your mouth or teeth caused you to… (Please circle one response) All of the time Very Often Fairly Often Sometimes Never a. Have difficulty sleeping? 1 2 3 4 5 b. Stay home more than usual? 1 2 3 4 5 c. Take time off work or school? 1 2 3 4 5 d. Be unable to do household chores? 1 2 3 4 5 e. Avoid your usual leisure activities? 1 2 3 4 5

PAGE 23

183. Thinking about your dental health over the past month, how often… All of the time Very Often Fairly Often Sometimes Never a. Have you been prevented from eating foods you would like to eat? 1 2 3 4 5 b. Have you found your enjoyment of food is less than it used to be? 1 2 3 4 5 c. Did it take you longer to finish a meal than other people? 1 2 3 4 5 d. Did you have difficulty pronouncing any words? 1 2 3 4 5 e. Did you have difficulty speaking clearly? 1 2 3 4 5 f. Did you have difficulty making yourself understood? 1 2 3 4 5 4. During the past month, how much pa in or discomfort have your teeth or mouth caused you? (please circle one response) 1 a great deal of pain 2 some pain 3 a little pain 4 no pain at all 5. Are you having any other problems or concerns about your teeth or mouth? If so, please describe. ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________

PAGE 24

19 REFERENCES Atchison KA. General Oral Health Assessment Index. In: Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill: University of North Carolina, Dental Ecology 1997. Atchison KA, Dolan TA. Development of the Geriatric Oral Health Assessment Index. J Dent Educ 1990; 54: 680-87. Bergstrom K, Halling A, Wilde B. Orthodontic care from the patients’ perspective: perceptions of 27-year-olds. Eu r J Orthod. 1998 Jun; 20(3):319-29. Breece GL, Nieberg LG. Motivations for adu lt orthodontic treatment. J Clin Orthod. 1986 Mar; 20(3):166-71. Day RL. Toward a process model of c onsumer satisfaction. In: Hunt HK (ed.) Conceptualization of Consumer Satis faction and Dissatisfaction. Cambridge: Marketing Science Institute, 1977 Dolan TA, Gooch BR. Dental Health questions form the Rand Health Insurance Study. In: Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill: University of North Carolina, Dental Ecology 1997. Feine JS, Lavigne GJ, Dao TT, Morin C, Lund JP. Memories of chronic pain and perceptions of relief. Pain. 1998 Aug;77 (2):137-41. Fernandes LM, Espeland L, Stenvik A. The provision and outcome of orthodontic services in a Norwegian community: a l ongitudinal cohort study. Community Dent Oral Epidemiol. 1999 Jun; 27(3):228-34. Kiyak HA, McNeill RW, West RA. The emoti onal impact of orthognathic surgery and conventional orthodontics. Am J Orthod. 1985 Sep;88 (3):224-34. Kuhlberg AJ, Glynn E. Treatment planning cons iderations for adult patients. Dent Clin North Am. 1997 Jan; 41(1):17-27. Lew KK.Attitudes and perceptions of adults to wards orthodontic treatment in an Asian community.Community Dent Oral Epidemiol. 1993 Feb; 21(1):31-5. Linder-Pelz S. Toward a theory of pati ent satisfaction. Soc Sci Med 1982; 16:577-582

PAGE 25

20 Locker D. Subjective oral health status indi cators. In: Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill: University of North Carolina, Dental Ecology 1997. McKiernan EX, McKiernan F, Jones ML. Psyc hological profiles and motives of adults seeking orthodontic treatment. Int J Adult Orthodon Orthognath Surg. 1992; 7(3):187-98. Miller JA. Studying satisfaction, modifying models eliciting expectations, posing problems, and making meaningful measurements. In: Hunt HK (ed.) Conceptualization of Consumer Satis faction and Dissatisfaction. Cambridge: Marketing Science Institute, 1977 Nattrass C, Sandy JR. Adult orthodontics--a review. Br J Orthod. 1995 Nov; 22(4):331-7. Nurminen L, Pietila T, Vinkka-Puhakka H. Motivation for and satisfaction with orthodontic-surgical treatment: a retrosp ective study of 28 patients. Eur J Orthod. 1999 Feb; 21(1):79-87. O'Brien K, Kay L, Fox D, Mandall N. Assessi ng oral health outcomes for orthodontics-measuring health status and quality of life. Community Dent Health. 1998 Mar;15(1):22-6. Proffit WR Special considerations in comprehensive treatment of adults. In: Contemporary Orthodontics. 2nd ed. St. Louis: MosbyYear Book; 1993: 585-606. Proffit WR, Fields HW, Moray LJ. Relevance of malocclusion and orthodontic treatment need in the United States: estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg. 1998; 13(2):97-106. Sergl HG, Zentner A. Study of psychosocial as pects of adult orthodont ic treatment. Int J Adult Orthodon Orthognath Surg. 1997; 12(1):17-22. Sinha PK, Nanda RS, McNeil DW. Perceived or thodontist behaviors th at predict patient satisfaction, orthodontist-patient relationshi p, and patient adherence in orthodontic treatment. Am J Orthod Dentof acial Orthop. 1996 Oct; 110(4):370-7. Stenvik A, Espeland L, Berset GP, Eriksen HM. Attitudes to malocclusion among 18and 35-year-old Norwegians. Community Dent Oral Epidemiol. 1996 Dec; 24(6):390-3. Vig KW, Weyant R, O'Brien K, Bennett E. Developing outcome measures in orthodontics that reflect patient and provider valu es. Semin Orthod. 1999 Jun; 5(2):85-95.

PAGE 26

21 BIOGRAPHICAL SKETCH Brett Thomas Lawton was born in Winter Pa rk, Florida. He received his Bachelor of Arts degree in neuroscience and a minor in Spanish from Vanderbilt University in Nashville, Tennessee, in 1996. He received his Doctor of Dental Me dicine degree from the University of Kentucky in Lexingt on, Kentucky, in 2000. Dr. Lawton continued his dental education at the Univers ity of Florida to receive his Ma ster of Science degree with a certificate in orthodontics. At the University of Florid a Dr. Lawton was involved in clinical research analyzing the psychoso cial impacts patients experience while undergoing orthodontic treatment.


Permanent Link: http://ufdc.ufl.edu/UFE0000728/00001

Material Information

Title: Orthodontic Psychosocial Impacts
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0000728:00001

Permanent Link: http://ufdc.ufl.edu/UFE0000728/00001

Material Information

Title: Orthodontic Psychosocial Impacts
Physical Description: Mixed Material
Copyright Date: 2008

Record Information

Source Institution: University of Florida
Holding Location: University of Florida
Rights Management: All rights reserved by the source institution and holding location.
System ID: UFE0000728:00001


This item has the following downloads:


Full Text











ORTHODONTIC PSYCHOSOCIAL IMPACTS


By

BRETT THOMAS LAWTON


















A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SCIENCE

UNIVERSITY OF FLORIDA


2003















ACKNOWLEDGMENTS

To my family, Mother and Father, and Lisa, I am grateful for their help and

support. My accomplishments would not have been possible without their love and

patience over the years.

To my wife, Laura, and daughter, Annabelle, I am very grateful for the patience

and support they have provided me throughout the many years of training. I look forward

to our lifetime of happiness.

To my committee-Drs. Wheeler, Dolan, Dolce, and McGorray-I appreciate their

dedication to me and insuring success throughout my training. I sincerely respect each of

them and their commitment to research and academic excellence.
















TABLE OF CONTENTS

Page

A C K N O W L E D G M E N T S ............................................................................................... ii

ABSTRACT ..................................... ...... .............. iv

IN TR OD U CTION ..................................................................... .. ..... .. ........

M A TERIALS AND M ETH OD S............................................................. ............... 4

R E S U L T S ...................................................... .......................... 8

D ISC U SSIO N ....................................................... ................. ....... ......... 12

C O N C L U S IO N S ......................................................... .................................... .. 16

APPENDIX. EXAMPLE OF SURVEY ADMINISTERED AT EACH DATA
C O LLEC TIO N TIM E PO IN T ..................................... .................... ....................... 17

REFEREN CES ..................... ...... ............ .. .. .. ....... .......19

BIO GR APH ICAL SK ETCH .................................................. .............................. 21















Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

ORTHODONTIC PSYCHOSOCIAL IMPACTS
By

Brett Thomas Lawton

May 2003

Chair: Timothy T. Wheeler
Major Department: Orthodontics

The treatment impacts experienced by patients undergoing different orthodontic

treatment modalities are essentially unknown. With the advent of contemporary

techniques such as Invisalign, this information may prove to be influential for both the

patient and practitioner. As a component of an ongoing prospective clinical trial we

assessed the psychosocial impacts of orthodontic treatment on 37 patients with traditional

edgewise appliances in comparison to one hundred patients undergoing treatment with

Invisalign. Impacts were assessed using a modified General Oral Health Assessment

Index (GOHAI). Participants completed surveys at pretreatment baseline, 3, 6, 12, and 18

months and at the completion of treatment. The treatment groups were comparable in

terms of age, sex, race, marital status, and previous orthodontic treatment. However, the

Invisalign group showed higher levels of education and income (p=0.02), which may

influence the reports of treatment impact. There were limited differences in the

experience patients undergo regardless of which treatment method is used. One exception

was that Invisalign patients reported more impacts at 6 months in comparison to

iv










edgewise patients (p=0.02). However, this difference was not appreciable at any other

time. Overall, the two treatment groups reported similar treatment impacts, with few

differences by treatment method.














INTRODUCTION

The psychosocial impacts of orthodontic treatment on patients have not been well

studied. Better understanding of treatment impacts including pain, discomfort, difficulty

chewing, eating or swallowing or interference with daily activities could facilitate patient

expectations during treatment. Moreover, as new techniques are introduced to the

orthodontic armamentarium, it is crucial that both parties are aware of key differences that

exist specific to the proposed means of treatment.

Medical and dental practitioners are experiencing a radical transformation from the

traditional, intuitive, unsystematic and paternalistic ideology of providing care to one

respecting evidence-based, patient-centered outcomes (Fernandes et al., 1999). A

dichotomy of information now exists between (1) the clinician formulating a rational,

objective means for treatment, and (2) the consumer perspective and subjective information

one regards as integral to a successful outcome (Vig et al., 1999). Whereas the foundation

for bridging communication between patient and provider has been established, a

significant divide still exists which hinders each party's ability to express more subjective

emotions including satisfaction and expectations.

The satisfaction a patient feels towards treatment is often difficult to define and

assess. In the simplest of terms, satisfaction may be understood as fulfillment one receives

resulting from an event or service (Miller, 1977). A more contemporary definition states

that treatment satisfaction amounts to the difference between what the patient expects and

what the patient receives (Vig et al., 1999; Day, 1977). A more philosophical









understanding of treatment satisfaction involves the individual's perceived value of

services provided and the resultant behavior they express as a result (Linder-Pelz, 1982;

Vig et al., 1999).

Contemporary medicine and dentistry have been subject to an emerging trend of

analyzing patient satisfaction. It is clear that this term satisfaction is rather broad in scope,

composed of many unique aspects that combine to portray a sense of satisfaction with

treatment. Such factors include well studied ideas including happiness with providers,

opinion of treatment results, and convenience of care provided. However, psychosocial

impacts including pain, discomfort, difficulty in chewing and interference of social

interaction have not been analyzed. Patients undergoing orthodontic treatment may

experience significant psychosocial impacts including the inability to speak clearly, eat

efficiently, sleep or relax, smile without embarrassment, or maintain their normal

emotional, social or business roles and responsibilities.

There is little literature concerning patient experience and attitude towards

orthodontic therapy (Lew, 1993). Current quality of life measures developed for dentistry

are commonly inapplicable to assess such interactions in orthodontics (O'Brien et al.,

1998) given the lack of a diseased state of oral health and the elective nature of cosmetic

treatment. Furthermore, extended duration of orthodontic treatment and cyclic,

intermittent discomfort associated with activation of appliances establish the experience

patients undergo to be unique. The orthodontic patient population, their motivation and

their expectations for a pleasing outcome are key factors that must be considered to

accurately report patient satisfaction with the orthodontic experience. It then becomes










necessary to further our understanding of the subjective perceptions patients experience

while undergoing orthodontic treatment.

The Department of Orthodontics at the University of Florida was commissioned

to execute a prospective clinical trial of 100 Invisalign patients to analyze a number of

factors. We felt the psychosocial impacts associated with various orthodontic treatment

modalities were in need of further study. Thus, the opportunity to compare these impacts

between subjects undergoing edgewise or Invisalign treatment was available and

convenient for study. This pilot study was designed to capture the self-reported impacts

both populations experience in hopes that we may more clearly understand how

influential differing modalities of treatment affect orthodontic patients.














MATERIALS AND METHODS

A prospective, longitudinal study was conducted to compare the influences that

orthodontic treatment had on patients with traditional edgewise appliances in comparison to

others undergoing treatment with Invisalign in a current clinical trial. All subjects were

treated in the resident, faculty or research orthodontic clinics at the University of Florida,

College of Dentistry in Gainesville, Florida. Subjects were at least 18 years of age, willing

to sign informed consent, in good health, and able to be treated without extractions

excluding a single lower incisor or third molars. The institutional review board for research

at the University of Florida approved the protocol prior to beginning the study.

One hundred Invisalign and thirty-seven edgewise patients were recruited to

participate in the study. Five Invisalign and three edgewise patients dropped out of the

study for a final sample of 95 and 34 patients, respectively. Unique identification

numbers were assigned to each patient. The sample consisted of 85 females and 44 males,

and a mean age of 29.1 years ranging froml8 to 58 years.

The surveys administered [see appendix] were a compilation of previously

described methods used in the general oral health assessment index (GOHAI), the Rand

Health Insurance study (RHIS) and contemporary work by Locker (1997). The GOHA

index is regarded as a valid means in relating psychosocial effects of one's oral health

condition without the presence of a disease state (Atchison, 1997; Atchison and Dolan,

1990). This index was designed to evaluate three aspects of oral health status: 1) physical

function (i.e. eating, speech, and swallowing); 2) psychosocial function (anxiety, concern









about oral health, withdraw from social interactions secondary to oral health status); and

3) pain or discomfort of the oral cavity. The RHIS study aimed to quantify the amount of

pain, worry and concern with social interactions secondary to diseased oral health status.

Locker modified these methods by recording nominal and ordinal responses pertaining to

subjects' ability to function in specific cases such as chewing firm meat, or eating an

apple. The compilation of these three indices resulted in the four questions that were

asked as a part of the survey. The fifth question was open ended and allowed for any

additional input the patient desired to share with the researcher in regards to their oral

health status.

Participants completed identical surveys at baseline/pre-treatment, 3-, 6-, 12- and

18 months and at the end of treatment [see appendix]. Surveys were administered at the

beginning of each visit corresponding to the data collection time point. Subjects

completed the survey based on their experience since their last orthodontic visit.

Demographic data was also collected from both samples [Table 1].

All responses were recorded in an ordinal manner with one open-ended question

for patients to make additional notes if necessary. The ordinal responses from each of the

four questions were summed and compared. The mean and median values for each

population were then compared. Figures 2-5 graphically represent the recorded responses

for each question over the aforementioned time points. The demographic and survey data

were evaluated by means of Wilcoxon Rank Sum and two-sample t-tests. Spearman

correlation coefficients were used to evaluate similarities between the two populations.











Table 1: Summary of Demographic Data

Invisalign Edgewise
Age
Mean Age in years 30.6 27.5
Standard Deviation 9.54 9.09
Minimum 18.1 18.8
Maximum 56.4 58.4

Education Level
HS Graduate 10% 16%
Some College 31% 28%
College Graduate 59% 50%

Income
under $10,000 11% 20%
10,000-25,000 16% 36%
25,000-50,000 26% 19%
50,000-75,000 24% 6%
75,000-100,000 7% 6%
100,000+ 16% 13%

Marital Status (%)
married 46% 34%
divorced 6% 9%
never married 47% 56%

Previous Ortho Treatment
No 78% 69%
Yes 22% 31%

Race Information
Black 7% 10%
Hispanic 7% 6%
Other 6% 9%
White 80% 75%

Sex
Female (n=85) 68% 59%
Male (n=44) 32% 41%

Students
No 57% 38%
Yes 43% 62%














RESULTS

A significant number of baseline differences were detected between the two

populations in question [Figures 1-4]. Questions 1, 3 and 4 indicate the Inivisalign

sample began treatment with less dental impacts than the edgewise group, although

significant changes were appreciable throughout the course of treatment. Because of the

baseline differences, we adjusted the data to reflect the changes from each group's

baseline to more accurately reflect the impact change over time. When comparing each

population's change from baseline, it appears the Invisalign population is more

negatively impacted at 6 months than the edgewise sample (p=0 .0253). However, this

relationship appeared transient and was not demonstrated at the following data collection

time point of one year.

Positive correlations in both samples indicate consistent relationships in the

survey responses [Table 2], although no significant correlation existed within the

edgewise group between survey [see appendix] questions 2 and 4 (r2= 0.08, p=0.12) and

questions 3 and 4 (r2= 0.08, p=0.10). Given these correlations, the applied survey appears

to elicit similar relationships each sample group recorded.

Demographic information [Table 1] showed similarities in both sample

groups. The study population consisted of approximately twice as many women (n=85)

as compared to men (n=44), at least 50% with college degrees, and approximately 2/3

receiving previous orthodontic treatment. The Invisalign population reported a

significantly higher annual income (p=0.0234) [Figure 5] and had more education,











although this finding was not statistically significant (p=0.07). The edgewise group was

composed of more current students than Invisalign (p=0.052). No significant differences

were appreciable between groups in marital status, age, sex, race or history of previous

orthodontic treatment.






Question 1 Invisalign
Invisalign
0 Edgewise
54
53
.2 52
1 51
50
49
l 48
47
46
Baseline 3 months 6 months 12 months
Timepoint

Figure 1: Mean recorded values from survey question 1 for
time points baseline through 12 months. Significant baseline
differences appreciable between groups. Invisalign started
off higher (better), and tends to report more positive findings
over time. Edgewise group is significantly lower at baseline
and 3 months, equal at 6 months, and slightly lower at 12
months. Slight upward trend appreciable for both samples.












Question 2 0 Invisalign
0 Edgewise
26

25 -

S24

T 23 -

r 22

21

20
Baseline 3 months 6 months 12 months
Timepoint

Figure 2: Mean recorded values from survey question 2 for
time points baseline through 12. months. No significant
differences appreciable in the societal and professional
impacts between treatment groups.

Question 3 Invisalign
0 Edgewise
30

29

28

-7-

C 26

S 25

24
Baseline 3 months 6 months 12 months
Timepoint

Figure 3: Mean recorded values from survey question 3 for
time points baseline through 12 months. Higher recorded
value indicates less impact on eating and speaking. Similar
differences reported over time. Invisalign tends to report
more positive findings over time.












Question 4
0 Edgewise
4.5
0 4
S3.5 -



o 2
1.5 -

0.5 -
0
Baseline 3 months 6 months 12 months
Timepoint

Figure 4: Higher recorded value indicates less pain.
Significant baseline differences indicate Invisalign sample
had less baseline dental discomfort. Demonstrates minimal
negative impact upon reported pain levels overall.









Income Differences


l IuiL.ci


dC A- ^- A ^
O H/' < ul ^o-7
Annual Income


* Invisalign
o Edgewise


Figure 5: Reported annual income of the study group.




Table 2: Spearman correlation coefficients for each population. Positive correlation
indicates similarity in responses within and between groups. All correlations were
significant except for questions 2 and 4 and questions 3 and 4 for the edgewise group.


Question 1

Question 2

Question 3


Invisalign Correlations
Question 2 Question 3
r=0.27 r=0.51
p=0.009* p<0.001*
r=0.25
p=0.0131*


Question 4
r=0.23
p=0.0246*
r=0.35
p=0.0005*
r=0.36
p=0.0003*


Edgewise Correlations
Question 2 Question 3 Question 4
Question 1 r=0.37 r=0.48 r=0.6
p=0.046* p=0.0068* p=0.0004*
Question 2 r=0.5 r=0.29
p=0.004* p=0.12
Question 3 r=0.29
p=0.10















DISCUSSION

The results of this study regarding the psychosocial impacts of orthodontic care

are inconclusive. Few significant differences between sample groups are appreciable.

Moreover, there were significant baseline differences that make comparison of each

group difficult and perhaps misleading. To adjust for baseline differences, we compared

the difference each sample group experienced since baseline. The one significant

difference observed between the edgewise and Invisalign group at 6 months was

transient and not appreciable at the following data collection time point of 12 months.

No clear explanation is available to justify this finding. One may speculate the

edgewise patients may have experienced the majority of discomfort early on, and now

appreciate the results as their chief complaint has been resolved. It is possible that the

Invisalign sample may be dissatisfied in the progress at this time, especially if the

aligners are not fitting correctly, if they require extensive interproximal reduction, or

perhaps requiring their case to be rebooted due to inconsistencies. Why this concern is

not appreciable at one year is unfounded.

When analyzing the results for each question, several interesting points are

noteworthy. Question 1 elicited a more positive response from Invisalign patients over

time, although both sample groups demonstrate a slight upward trend. Question 2

demonstrated very little difference in the societal and functional impacts each sample

experienced. This finding suggests that orthodontic treatment regardless of modality has

little, if any, impact on patients' professional roles and social responsibilities. Question 3









addresses similar concerns to question 1 in regards to the impact on patients' ability to eat

or speak effectively. Invisalign patients reported significantly more positive findings over

time indicating less impact from treatment. Question 4 addressed the level of pain or

discomfort for each population. A significant baseline difference was noted as edgewise

patients elicited responses suggestive of more dental pain in comparison to the Invisalign

sample. This difference in reported discomfort was not significant at other time points.

The study population was unique for several reasons in comparison to the typical

adolescent population that dominates most orthodontic practices. Approximately three

times as many adult women elect to receive treatment compared to men (Nattras et al.,

1995), and whom at least half have received a college education (Sergl and Zentner,

1997; Kiyak et al., 1985). Approximately 20% (McKieman et al., 1992) to 50% (Sergl

and Zentner, 1997) have undergone previous orthodontic treatment.

The increase in the number of adults seeking orthodontic treatment has been

attributed to a number of possible factors, including increased public awareness,

increased preoccupation with health and appearance, the increased availability of

resources, and expanded demand for orthodontic support to other dental specialties

(McKieman et al., 1992). In addition, Breece and Nieberg have reported a general

increase in social acceptability of appliance therapy (Breece and Nieberg, 1986).

Technologic advances have played a significant role in this phenomenon with the advent

of long-duration memory wires, low profile or ceramic brackets (Kuhlberg et al., 1997),

and contemporary treatment modalities, such as Invisalign. (Nattrass et al., 1995)

The data in this study suggest limited differences in treatment impacts exist

between the Invisalign or edgewise populations. Literature in support of this finding









suggests adults may be less influenced by their peer perceptions, and are more stable in

their concerns about appearance compared to adolescents (Stenvik et al., 1996). Indeed,

many authors recognize the desire for improvement as a sign of ego strength not

weakness (Kiyak et al., 1984; Proffit, 1993). The preliminary data from this pilot study

may suggest adults do not appreciate a significant difference in how Invisalign or

edgewise appliances influence their lives, but moreover how orthodontic treatment in

general affects them.

Several potential weaknesses to this study are worthy of mention. Feine and

colleagues (Feine et al., 1998) reported patients cannot accurately recall differing

intensities of pain over time, and the perceived discomfort greatly depends on the level of

pain before treatment. The literature suggests the discomfort these subjects reported is not

accurate given the retrospective nature in which they were polled, and the extended

duration of time between data collection time points ranging from one to 6 months.

Furthermore, subjects were polled to record the treatment impacts since their last visit,

which may be highly variable and deceiving for each patient. It is likely that key

differences exist between the two samples immediately following the initiation of

treatment or shortly after a change in wires or aligners. As a result of these unknown

variables, a study to record these differences by means of a similar survey administered

daily for one week immediately following the first day of active treatment has been

started.

Several weaknesses existed in the sample populations for this study. The

Invisalign population was concurrently involved in an ongoing university study

analyzing a multitude of factors in addition to this survey. Variations in treatment









requirements, mechanics and protocols associated with such a clinical trial may

compound the variability in this data, and may not be reflective of the experience in

private practice. The sample size difference is significant between the two populations

studied. The edgewise population was limited primarily due to the lack of adult patients

meeting the inclusion criteria in the university setting. Lastly, the significant differences

at baseline limit the ability to draw firm conclusions regarding the difference in impacts

experienced by each sample group. Further study of patient satisfaction in the private

sector has been initiated to evaluate these potential differences.















CONCLUSIONS

Although this study did not demonstrate any appreciable differences in treatment

impacts between edgewise and Invisalign patients, further study is indicated.

Orthodontists should be concerned for the satisfaction of patients and the impacts of

treatment. Likewise, the success of patient treatment and the specialty of orthodontics

demand a better understanding of the emotional and functional transformations incurred

in orthodontics. Such information will certainly be of great benefit to both the patient and

the practitioner.


















APPENDIX
EXAMPLE OF SURVEY ADMINISTERED AT EACH
DATA COLLECTION TIME POINT



1. Please circle one response for each of the following questions.

In the past month, how often: Always Often Some- Seldom Never
times
a. did you limit the kinds or amounts of food you eat
because of problems with your mouth or teeth? 1 2 3 4 5
b. did you have trouble biting or chewing any kinds of
food, such as firm meat or apples? 1 2 3 4 5
c. were you able to swallow comfortably? 1 2 3 4 5
d. did your teeth prevent you from speaking the way
you wanted? 1 2 3 4 5
e. were you able to eat anything without feeling
discomfort? 1 2 3 4 5
f did you limit contact with people because of the
condition of your mouth or teeth? 1 2 3 4 5
g. were you pleased or happy with the looks of your
mouth or teeth? 1 2 3 4 5
h. did you use medication to relieve pain or discomfort
from around your mouth? 1 2 3 4 5
i. were you worried or concerned about the problems
with your mouth or teeth? 1 2 3 4 5
j. did you feel nervous or self-conscious because of
problems with your mouth or teeth? 1 2 3 4 5
k. did you feel uncomfortable eating in front of people
because of problems with your mouth or teeth? 1 2 3 4 5
1. were your teeth sensitive to hot, cold, or sweets?
1 2 3 4 5


2. During the past month, how often has pain, discomfort, or other problems with your mouth or teeth caused you
to... (Please circle one response)

All of the Very Fairly Some-
time Often Often times Never
a. Have difficulty sleeping? 1 2 3 4 5
b. Stay home more than usual? 1 2 3 4 5
c. Take time off work or school? 1 2 3 4 5
d. Be unable to do household chores? 1 2 3 4 5
e. Avoid your usual leisure activities? 1 2 3 4 5











3. Thinking about your dental health over the past month, how often...

All of the Very Fairly Some-
time Often Often times Never
a. Have you been prevented from eating foods you 1 2 3 4 5
would like to eat?
b. Have you found your enjoyment of food is less than 1 2 3 4 5
it used to be?
c. Did it take you longer to finish a meal than other 1 2 3 4 5
people?
d. Did you have difficulty pronouncing any words? 1 2 3 4 5
e. Did you have difficulty speaking clearly? 1 2 3 4 5
f Did you have difficulty making yourself understood? 1 2 3 4 5


4. During the past month, how much pain or discomfort have your teeth or mouth caused you? (please circle one
response)
1 a great deal of pain
2 some pain
3 a little pain
4 no pain at all

5. Are you having any other problems or concerns about your teeth or mouth? If so, please describe.















REFERENCES


Atchison KA. General Oral Health Assessment Index. In: Slade GD, ed. Measuring Oral
Health and Quality of Life. Chapel Hill: University of North Carolina, Dental
Ecology 1997.

Atchison KA, Dolan TA. Development of the Geriatric Oral Health Assessment Index. J
Dent Educ 1990; 54: 680-87.

Bergstrom K, Halling A, Wilde B. Orthodontic care from the patients' perspective:
perceptions of 27-year-olds. Eur J Orthod. 1998 Jun; 20(3):319-29.

Breece GL, Nieberg LG. Motivations for adult orthodontic treatment. J Clin Orthod. 1986
Mar; 20(3):166-71.

Day RL. Toward a process model of consumer satisfaction. In: Hunt HK (ed.)
Conceptualization of Consumer Satisfaction and Dissatisfaction. Cambridge:
Marketing Science Institute, 1977

Dolan TA, Gooch BR. Dental Health questions form the Rand Health Insurance Study.
In: Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill:
University of North Carolina, Dental Ecology 1997.

Feine JS, Lavigne GJ, Dao TT, Morin C, Lund JP. Memories of chronic pain and
perceptions of relief. Pain. 1998 Aug;77 (2):137-41.

Fernandes LM, Espeland L, Stenvik A. The provision and outcome of orthodontic
services in a Norwegian community: a longitudinal cohort study. Community Dent
Oral Epidemiol. 1999 Jun; 27(3):228-34.

Kiyak HA, McNeill RW, West RA. The emotional impact of orthognathic surgery and
conventional orthodontics. Am J Orthod. 1985 Sep;88 (3):224-34.

Kuhlberg AJ, Glynn E. Treatment planning considerations for adult patients. Dent Clin
North Am. 1997 Jan; 41(1):17-27.

Lew KK.Attitudes and perceptions of adults towards orthodontic treatment in an Asian
community.Community Dent Oral Epidemiol. 1993 Feb; 21(1):31-5.

Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med 1982; 16:577-582









Locker D. Subjective oral health status indicators. In: Slade GD, ed. Measuring Oral
Health and Quality of Life. Chapel Hill: University of North Carolina, Dental
Ecology 1997.

McKiernan EX, McKieman F, Jones ML. Psychological profiles and motives of adults
seeking orthodontic treatment. Int J Adult Orthodon Orthognath Surg. 1992;
7(3):187-98.

Miller JA. Studying satisfaction, modifying models eliciting expectations, posing
problems, and making meaningful measurements. In: Hunt HK (ed.)
Conceptualization of Consumer Satisfaction and Dissatisfaction. Cambridge:
Marketing Science Institute, 1977

Nattrass C, Sandy JR. Adult orthodontics--a review. Br J Orthod. 1995 Nov; 22(4):331-7.

Nurminen L, Pietila T, Vinkka-Puhakka H. Motivation for and satisfaction with
orthodontic-surgical treatment: a retrospective study of 28 patients. Eur J Orthod.
1999 Feb; 21(1):79-87.

O'Brien K, Kay L, Fox D, Mandall N. Assessing oral health outcomes for orthodontics--
measuring health status and quality of life. Community Dent Health. 1998
Mar;15(1):22-6.

Proffit WR Special considerations in comprehensive treatment of adults. In:
Contemporary Orthodontics. 2nd ed. St. Louis: Mosby-Year Book; 1993: 585-606.

Proffit WR, Fields HW, Moray LJ. Relevance of malocclusion and orthodontic treatment
need in the United States: estimates from the NHANES III survey. Int J Adult
Orthodon Orthognath Surg. 1998; 13(2):97-106.

Sergl HG, Zentner A. Study of psychosocial aspects of adult orthodontic treatment. Int J
Adult Orthodon Orthognath Surg. 1997; 12(1):17-22.

Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviors that predict patient
satisfaction, orthodontist-patient relationship, and patient adherence in orthodontic
treatment. Am J Orthod Dentofacial Orthop. 1996 Oct; 110(4):370-7.

Stenvik A, Espeland L, Berset GP, Eriksen HM. Attitudes to malocclusion among 18-
and 35-year-old Norwegians. Community Dent Oral Epidemiol. 1996 Dec;
24(6):390-3.

Vig KW, Weyant R, O'Brien K, Bennett E. Developing outcome measures in
orthodontics that reflect patient and provider values. Semin Orthod. 1999 Jun;
5(2):85-95.















BIOGRAPHICAL SKETCH

Brett Thomas Lawton was born in Winter Park, Florida. He received his Bachelor

of Arts degree in neuroscience and a minor in Spanish from Vanderbilt University in

Nashville, Tennessee, in 1996. He received his Doctor of Dental Medicine degree from

the University of Kentucky in Lexington, Kentucky, in 2000. Dr. Lawton continued his

dental education at the University of Florida to receive his Master of Science degree with

a certificate in orthodontics. At the University of Florida Dr. Lawton was involved in

clinical research analyzing the psychosocial impacts patients experience while

undergoing orthodontic treatment.