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Patients’ expectations of orthodontic treatment: Part 2—findings from a questionnaire survey

Orthodontic Department, Eastman Dental Institute, London, UK

J. T. Newton

Department of Oral Health Services & Dental Public Health, King’s College, London, UK

Address for correspondence: Mr M. Sayers, Orthodontic Department, Eastman Dental Institute, 257 Gray’s Inn Road, London WC1X 8LD, UK., Email: marksayers29{at}hotmail.com

Received 16 June 2005; accepted 20 July 2006

	Abstract

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Objective: To describe patients’ and their parents’ expectations of orthodontic treatment.

Design: A questionnaire survey of 100 patients and their primary care-givers attending a new patient orthodontic consultant clinic, at a teaching hospital.

Setting: GKT Orthodontic Department, King’s College Dental Hospital, London, UK.

Subjects: The sample consisted of 100 participants who completed the questionnaire, including 50 patients aged 12–14 years who had been referred to the orthodontic department for treatment. One parent of each patient was also invited to participate.

Materials and methods: Participants completed a valid questionnaire measure of orthodontic expectations that was tested for reliability and validity. Descriptive analysis of the responses was undertaken, and comparisons of children’s and parents’ expectations, in addition to ethnicity, were made.

Results: Patients and parents have similar expectations of treatment, with the exception of expectations of duration of orthodontic treatment (P<0.01), having a brace fitted at the initial visit (P<0.05), and restrictions with regard to what one can eat and drink as a result of orthodontic treatment (P<0.05). Among the patient participants, different ethnic groups displayed different expectations of the initial orthodontic assessment visit, the likelihood of wearing headgear, the impact of orthodontic treatment on diet, and the reaction of peers to treatment (P<0.05). For patients, ethnic group differences were reported for expectations regarding the initial visit, headgear and dietary restrictions (P<0.05).

Conclusions: Patients and their parents share similar expectations of orthodontic treatment for most aspects of care, although parents are more realistic in their estimation of the duration of treatment and the initial visit. The expectations of patients differ from those of their parents with regard to dietary and drink restrictions in relation to orthodontic treatment. Ethnicity significantly influences expectations of orthodontic treatment, and this may relate to differences in the patients’ and their parents’ assessed outcome of care.

Key words: Patient expectations, orthodontics, questionnaire, measure

	Introduction

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There are few studies that have examined patients’ expectations of orthodontic treatment in the UK.

Studies have focused on parents’ expectations of orthodontic treatment, and have not directly measured patients’ expectations.^1,2 The questionnaires used to measure patients’ and parents’ expectations require further psychometric validation (reliability and validity tests).^2,3 In one study, an adaptation of a questionnaire to measure patients’ expectations of orthognathic surgery was used to measure patients’ expectations of orthodontic treatment.⁴

Other studies have measured patients’ and parents’ expectations during orthodontic treatment, which introduces bias into the results.^3,4 Another study measured patients’ expectations of pain resulting from wearing fixed orthodontic appliances, while the general expectations of orthodontic treatment were not investigated.⁵

There are few studies that have explored the relationship between orthodontic expectations and ethnicity. One author states that the social and cultural expectations with regard to dental appearance have changed with time in the USA. Social and cultural expectations and pressures produce a culturally valid need for orthodontic treatment, and social and cultural expectations condition peer and adult expectations.⁶

The orthodontic expectations of White Caucasians and Pakistani Muslim patients and their parents were investigated through semi-structured qualitative interviews.⁷ The authors explored the relationship between culture, language and inappropriate orthodontic expectations.

The aim of this article is to report patients’ and their parents’ expectations of orthodontic treatment when measured using a questionnaire that was psychometrically validated, and the relationship of ethnicity to patients’ and parents’ expectations of orthodontic treatment.

	Materials and methods

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Ethical approval was granted by King’s College Hospital Research Ethics Committee (LREC 02-123) and King’s College Research and Development Committee.

A questionnaire was used to measure patients’ and their parents’ expectations of orthodontic treatment (see Appendix 1). A visual analogue scale (VAS) marked at 10-mm intervals was used as the Likert response format for all questions except questions 8 and 9. Inclusion criteria for participation in the study were:

• new patients and their parents presenting to the orthodontic consultant clinic;
  
• patients aged 12–14 years;
  
• patients with no previous history of orthodontic treatment;
  
• consent obtained from both the child and the parent.
  

One hundred and seventy-four subjects were invited to participate in the study before attending their new-patient orthodontic consultation. They consisted of 87 patients and their 87 parents. An information sheet was given to both the patient and parent before written consent was obtained from both the child and their parent. Patients completed their questionnaires separately from the accompanying parent.

Comparisons of child and parent expectations, as well as expectations reported by different ethnic group, were made using statistical tests. However, no sample size calculations were made a priori, because this was a new questionnaire measure with no available data to make an estimate.

	Results

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Characteristics of the sample
A total of 100 subjects completed the questionnaire during the period December 2002–April 2003. They consisted of 50 patient participants aged between 12 and 14 years, and 50 of their parents (mean age 41 years). Sixty-three per cent of patient participants were female, and 68% of parent participants were female. The findings from the questionnaire were analysed using SPSS Version 10.0 (SPSS Corporation, Chicago, USA).

Comparison of child and parent participants
Responses from parent and child participants were compared. No statistically significant difference was seen between children’s and parents’ responses, except for questions 1a, 6 and 8 (Tables 1 and 2).

Question 8 showed statistically significant differences between child and parent participants’ responses (P<0.01). Table 2 shows that nearly 50% of child participants did not know how long orthodontic treatment would take. Twice as many child participants as parents expected orthodontic treatment to be completed within 1 year (Table 2).

Ethnicity
Ethnic classification was carried out according the UK census guidelines. Sixty-three per cent of participants classified themselves as British, and 10% as Caribbean; the other categories had smaller numbers of participants (Table 3). In order to analyse the data, two larger groups were constructed by combining groups A, B and C (White British, White Irish and other White backgrounds) to form group 1, and the remaining groups to form group 2.

	Discussion

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Both child and parent participants revealed low expectations of orthodontic treatment involving headgear, surgery or dental extractions. This may be one reason for poor compliance with headgear wear. It is also interesting to see that participants leaned towards non-extraction orthodontic treatment. Children and their parents did not expect pain and masticatory difficulties to be associated with orthodontic treatment. Firestone et al.⁵ reported that participants underestimated the changes that they need to make in their diet as a result of pain associated with orthodontic treatment. Child participants expected significantly greater restrictions with regard to the types of food and drink that they could consume during orthodontic treatment, in comparison to parent participants. This may be because children are more aware of the need for a low-sugar and low-acid diet, as a result of talking to their peers who may have undergone orthodontic treatment.

No negative reaction from the public was expected by child and parent participants with regard to the wearing of fixed orthodontic appliances. This probably reflects the normalization of orthodontic treatment in the Western world.⁶

Parents seemed to be more informed about the duration of orthodontic treatment than their children. As more children are wearing fixed orthodontic appliances, it would have been expected that this information would have been passed on in peer conversation. The duration of orthodontic treatment has been shown to be poorly understood in some ethnic minorities.⁷

Patients and their parents have high expectations that orthodontic treatment will produce straight teeth and a better smile. However, expectations are higher with regard to straight teeth compared to a better smile. Parents expected a higher increase in social confidence as a result of orthodontic treatment than their children, as shown by Tung and Kiyak.⁴

Participants felt that orthodontic treatment was unlikely to improve mastication, speaking or career prospects. Shaw et al.³ stated that patients and parents expected orthodontic treatment to improve mastication, speech, and success in future occupations.

Responses from the child participants revealed significant differences between the two ethnic groups. Non-White participants had greater expectations of orthodontic braces being fitted at their initial visit than White participants. Participants who identified themselves as White had greater expectations of a check-up and diagnosis and more realistic expectations of their initial visit than non-White participants.

With regard to orthodontic treatment, there were greater expectations of having to wear headgear in the non-White group than among White participants. It seemed that expectations of orthodontic treatment were more negative in the non-White group because they anticipated more pain and dietary restrictions than White participants.

Children who indicated that their ethnicity was non-White expected a more positive reaction from people with regard to their fixed orthodontic appliances. This reflects the different social–cultural expectations with regard to perfectly occluding teeth and a beautiful dentition.⁶

Differences in the benefits of orthodontic treatment were seen between the two child ethnic groups, as non-White children expected greater speech improvements. This may be because these children anticipated greater functional benefits of orthodontic treatment.

Parents who identified their ethnicity as White had a more realistic anticipation of their child’s initial visit, because they expected the first visit to be a check-up and diagnosis. This may be because they were better informed. Khan and Williams⁷ showed that there were expectation differences between White Caucasians and Pakistani Muslims with regard to orthodontic treatment. The authors state that Pakistani parents failed to understand what was involved and the duration of orthodontic treatment; this was largely due to language and cultural barriers.

Non-White parents expected headgear wear and more dietary and drink restrictions. White parents may not have anticipated changes to their child’s diet in the same way, because they viewed orthodontic treatment as a normal, unrestrictive procedure.⁶ This seems to be in disagreement with the study that showed that Pakistani parents failed to understand the dietary requirements involved in orthodontic treatment.⁷

Weaknesses of the study
The sample size limited full differentiation between all ethnic groups. Therefore, the groups were combined into two larger groups for analysis. Group 1 consisted of the White ethnic groups, and group 2 consisted of the other ethnic groups; this was similar to the method used by Tung and Kiyak.⁴ However, a larger sample size is required to analyse the effect that ethnicity has on orthodontic expectations for each ethnic group.

The effect of occupation on parents’ expectations of orthodontic treatment could not be analysed, because the sample size limited full differentiation into occupational groups. However, studies have shown that professional parents anticipate that straight teeth will aid future occupational success,³ and educated fathers and parents with higher incomes have increased expectations of the benefits of orthodontic treatment.² A larger sample is needed to explore the relationship between parents’ occupation and their expectations with regard to orthodontic treatment.

The results from the questionnaire are threatened by biases and errors.⁸ Biases could have resulted from mood bias (people in low spirits may underestimate their health status), non-response bias (patients not completing all the questions), and response style bias (participants responding to questions in the same manner regardless of the question). Random measurement error could occur when a respondent guesses or gives an unpredictable response. Selection bias is included, as only 12 to 14-year-old patients were investigated. Uninformed or equivocal expectations shown by patients and their parents may reflect a person’s inability or unwillingness to communicate their expectations.⁹ This could represent social desirability bias, which leads to a response set where participants wish to give a preferred image.⁹

Strengths of the study
Patients’ and their parents’ expectations of orthodontic treatment were measured using a psychometrically validated questionnaire based on a UK population, and not a modified questionnaire.⁸

Information was collected before the pre-treatment consultation, which reduced bias in responses. Other authorities have stated that orthodontists should ask patients about their expectations before treatment.¹⁰

The study collected data on patients’ and their parents’ expectations of their initial visit, type of treatment expected, problems associated with orthodontic treatment, duration and frequency of attendance, and the expected benefits of treatment.

The relationship between ethnicity and patients’ and their parents’ expectations was examined. This has not been widely explored in the published literature.

Clinical practice
The questionnaire could be used to assess unrealistic expectations and aid the consent and treatment-planning process. As a result of understanding patients’ anticipations, this measure may be used to reduce failed appointments, avoid premature termination of treatment, and increase patient compliance. These factors help to improve the quality of orthodontic treatment provided to the patient.

	Conclusions

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Information collected from 12 to 14-year-old patients and their parents with regard to orthodontic expectations reveals the following:

• Patients and their parents have similar expectations.
  
• Significant differences in orthodontic expectations were seen between patients and their parents with regard to their initial visit, and dietary and drinking restrictions, in addition to duration of treatment. Parents had lower expectations of orthodontic appliances being fitted at their child’s initial appointment than child participants (P<0.05). Children had greater expectations of dietary and drinking restrictions in relation to orthodontic treatment than parent participants (P<0.05). Parents had a more realistic expectation of the duration of orthodontic treatment (P<0.01).
  
• Ethnicity significantly influences children’s and parents’ expectations of orthodontic treatment (P<0.05). The extent of its influence requires further investigation.
  

	Contributors

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Mark Sayers was responsible for the recruitment of the participants, data collection, content analysis, designing the questionnaire and drafting the article. Tim Newton was responsible for study design, content analysis, statistical data analysis, critical revision, expert advice and final approval of the article. Professor Fraser McDonald helped in critical appraisal and advice. In addition, Liz O’Higgins, Shruti Patel and Mr Powell allowed access to recruitment of patients referred to their consultant clinics. Tim Newton is the guarantor.

View larger version (69K): [in this window] [in a new window]   Appendix 1

	References

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2 Bennett EM, Michaels C, O’Brien K, Weyant R, Phillips C, Vig KD. Measuring beliefs about orthodontic treatment: a questionnaire approach. J Public Health Dent 1997; 57: 215–23.[Medline]

3 Shaw WC, Gabe MJ, Jones BM. The expectations of orthodontic patients in South Wales and St Louis, Missouri. Br J Orthod 1979; 6: 203–5.[Medline]

4 Tung AW, Kiyak AH. Psychological influences on the timing of orthodontic treatment. Am J Orthod Dentofacial Orthop 1998; 113: 29–39.[CrossRef][Medline]

5 Firestone AR, Scheurer PA, Burgen B. Patients’ anticipation of pain and pain-related side effects and their perception of pain as a result of orthodontic treatment with fixed appliances. Eur J Orthod 1999; 21: 387–96.[Abstract/Free Full Text]

6 Jenny J. A social perspective on need and demand for orthodontic treatment. Int Dent J 1975; 25: 248–56.[Medline]

7 Khan FA, Williams S. Cultural barriers to successful communication during orthodontic care. Community Dent Health 1999; 16: 256–61.[Medline]

8 Bowling A. Research Methods in Health—Investigating Health and Health Services, 2nd Edn. Buckingham: Open University Press, 2002.

9 Thompson AG, Sunol R. Expectations as determinants of patient satisfaction: concepts, theory and evidence. Int J Qual Health Care 1995; 7: 127–41.[Abstract/Free Full Text]

10 Bos A, Hoogstraten J, Prahl-Andersen B. Expectations of treatment and satisfaction with dentofacial appearance in orthodontic patients. Am J Orthod Dentofacial Orthop 2003; 123: 127–32.[CrossRef][Medline]

This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Sayers, M. S. Articles by Newton, J. T. Search for Related Content PubMed PubMed Citation Articles by Sayers, M. S. Articles by Newton, J. T.