An occasionally irregular blog about orthodontics

Do orthodontic patients wear their removable appliances?

By on August 26, 2016 in Clinical Research, Recent posts with 7 Comments
Do orthodontic patients wear their removable appliances?

How long do patients wear their removable appliances?

One of the greatest problems with removable orthodontic appliances is that they require considerable amounts of patient co-operation. Recently, timing devices that can be fitted into removable appliances have been developed, so that we can measure patient co-operation. I came across this interesting paper that reported on a recent study that used timers to measure co-operation.  The results are surprising.

Objective assessment of compliance with intra- and extraoral removable appliances

Arreghini A et al

Angle Orthodontist: On line advance publication

DOI: 10.2319/020616-104.1

italy-ferrara-castello-estenseA team from Ferrara in Italy carried out this study. I have had the great pleasure of speaking in Ferrara and it is a remarkably beautiful town in Northern Italy. It is well worth a visit.

The introduction to the paper was very clear and was a nice summary of  orthodontic compliance. They pointed out that measures to increase and monitor compliance, such as self completion questionnaires are not accurate. Indeed, we are all familiar with the old ‘headgear chart’ that a patient filled in with the same pen that recorded 14 hours per day, every day!

They discussed the introduction of the TheraMon compliance system. This is a small device that measures the surrounding temperature and transmits data to a dedicated workstation.  It records the amount of time that the device has spent outside the oral cavity and gives us accurate data on patient co-operation.

This has been used on intra-oral removable appliances, but the authors pointed out that there has been limited work on measuring compliance with extra-oral appliances.  As a result, they set out to measure how well young patients wore their intra-oral and extra-oral appliances.

What did they do?

This was a prospective cohort study in which they followed the treatment of 30 consecutive patients, aged between 6 and 15 years.  They divided them into;

  • 14 Class II patients treated with a Frankel 2 or bionator.
  • 16 Class II patients treated with RME and protraction facemasks.

Before treatment each patient completed a psychometric questionnaire that measured the child’s beliefs in their ability to control his or her life (The locus of control questionnaire).

They asked the patients to wear their appliance for 13 hours per day.  They also randomly selected 14 patients and let them know that they were monitoring their co-operation. At each treatment appointment they examined the data from the timer and fed back to the patients.

What did they find?

The mean observation period was 8 months (range 2-16 months).

They found that the mean compliance time for the total sample was only 8.6 (SD 2.9) hours.  For the Frankel and bionator patients this was 9.5 (2.5) hours and for the protraction patients this was 8.0 (3.2) hours.

When they looked at compliance with time, they found that this remained  stable for the first 5 months of treatment and then started to drop.

They carried out a statistical analysis to evaluate if there was an effect of locus of control (from the questionnaire) or gender. But they did not detect any statistically significant effects.

Overall, they concluded that compliance with the appliances was very poor and was only for 65% of the time that they asked the patients to wear their appliances.

What did I think?

I have given this study some thought.  I do have some concerns that the sample size was too small and the study lacked statistical power. As a result, I did not really take much notice of the statistical testing that they carried out.

However, if we just treat this as a descriptive cohort study, it provides us with useful information on patient compliance.  In effect, our patients do not wear their appliances, as much as we would hope. Even when we tell them that they are being timed had little effect!

I have always thought that I would use a timer with my patients so that I could encourage co-operation by providing feedback to them and their parents (particularly their mother!).  But the results of this study suggest that this makes no difference.  I was surprised at this and it would be interesting to investigate this further.

We also have to consider the nature of the appliances that they used in the study. In some respects, I found it disappointing that they used the Frankel appliance, when there are other appliances that are  easier to wear. I certainly, ask for 24 hour wear with my Twin Block patients, but I do not know if I get it!  Protraction headgear is also challenging to wear, but I would have thought that we should get more than nighttime wear, as revealed in this study.

Another factor that we need to consider is the accuracy of the TheraMon timer.  While this has been tested, I am not sure that it is 100% accurate. But I am sure that someone can reassure me.

My final point is concerned with the effects of co-operation on the effects of treatment. I would have really liked to see data from this study on whether there was an influence of co-operation on the treatment results.  This is probably the most important question.  While we ask for maximum wear of appliances, we do not really know how long an appliance needs to be worn for our patients to achieve good treatment results.

Overall, this study does provide us with useful information.  I think that it is great that the development of timers can open up a really interesting field of orthodontic research.  This is an exciting development.

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  1. CHAS LISTER says:

    I always remember many years ago at KCH when one of the ortho Consults confirmed this with some headgear to heave the molars back …. the first case of a lass who actually wore it as prescribed, and the teeth flew back. Made us all realise that compliance was always an uncertain factor. The bar was set fairly low: if changes occur, they are above the compliance threshold for success and that is acceptable. It remains my mantra today. Its why some operators like to fix everything in that they can.

  2. These studies mean little. Cooperation is heavily based on internal patient motivation, motivation of the parent which often is related to socio economic status and finally the motivation encouragement and instruction of the orthodontist. None of this was measured. 100% cooperation is impossible but appliances shouldn’t be dismissed because they’re removeable.

  3. Adey Bennett says:

    Hi Kevin,
    Thanks, as usual for bringing another paper to our attention.
    I think there is benefit in being able to monitor how much an appliance is being worn. It allows us to assess whether the (lack of) progress during treatment is due to patient compliance or incorrect appliance design/ mechanics etc.

    I suspect it is similar with retainer compliance, and a similar monitoring device would be very useful, especially if patients complain that their treatment has relapsed.

  4. Useful to have something that will help with motivation and monitoring as it is essential for those post-treatment patients to continue to use mechanical means to prevent relapse.
    However ‘non-scientific’ it might appear to be, myofunctional therapy is of significant benefit in training the muscles of the tongue, cheeks and lips to re-establish optimal tongue posture – namely at the roof of the mouth – where the tongue, with correct muscle function, acts as nature’s retainer.
    It would be such a pleasant change if such ‘research’ also used something other than black or white – wear or non wear, to see if the outcomes can be improved. What we desperately want to avoid is the ongoing decline into airway dysfunction as the child/teenager gets older. There is no argument or denial of the fact that a patent airway is dependent on the integrity of the structures contained therein PLUS minimal inflammation and/or congestion in the vascular and mucous tissues which line the walls. From a scientific point of view it is not possible for an airway to “collapse” because it is a space – and a space cannot – in itself – collapse. The reduction in airway patency is a consequence of the malpositioning of the jaws, teeth and craniofacial structure, exacerbated by intermittent inflammation and congestion of airway lining due to hyperventilation and allergic responses – which are intimately interconnected. I will be one very happy camper when we can all discuss the human body in its entirety rather than its isolated specialities.

  5. These studies will be more and more interesting and important regarding the increase in demands for such treatments as Invisalign. They are removable appliances and we do need cooperation for it to work. We say 22 hours of wear everyday is needed, but it is easy to imagine that probably most of our patient do between 18 and 20 hours… If not less! Yet it still works! And we tell them to change aligners every two weeks, but more and more we see that changing aligners every week gives us the same results… If not better! And all without the use of any of these “accelerators” devices (thanks to your blog, we understand nothing has been proven that it changes something yet).
    So how much time is enough for our movements and effects to occur? And for what type of patients? Are children responding differently than adults. 20, 40, 60+ years old; do age changes something? Does metabolism have an effect on time of wear needed for a removable appliance to be effective? And is the needed compliance related to the type of treatment were doing? Does extrusion need more compliance than expansion? Does torque need more compliance than rotations? A lot of questions for a lot of possible studies. It will be necessary to do these studies in effort to understand better the future of orthodontics. Because, as we can read in the recent editorial of the JCO, it is now comfortable to say that today all patients can be treated with Invisalign.

  6. Hi Kevin,

    Whilst appreciating this paper was looking at compliance from young people for two specific types of appliance, I was left thinking about whether this study considered both the wider issue of patient engagement and communication and whether similar results would be received from adult patients undertaking orthodontic treatment?

    To address the first issue, it would be interesting to survey patients/carers a few days after receiving instruction from their orthodontist to ascertain what they understood from the conversation as it may be the case that what you say and what we hear is somewhat different. I’m certainly not suggesting that instruction is not clear but for patients to not comply with instructions that would be of benefit to their treatment, there must be a thought process that weighs the merits of what is recommended against what they actually decide to do. Understanding this may be the key to getting effective patient engagement and improved treatment outcomes. The inclusion of timer devices into appliances is a great tool for the orthodontist but with the application of technology, could this not be included into a competitive app that motivates the patient towards the recommended wear time? Maybe the motivation needs to be external to the treatment outcomes to ensure better compliance?

    In so far as adult orthodontics is concerned, I would be interested to learn what the compliance rate is for those requiring removable appliances (and you can include elastic wear in this). With most adult patients actively seeking and having a financial commitment in their treatment, I feel this may be part of the solution but certainly not all. It would be relatively easy for orthodontists to seek views from their adult patients about why they do or do not comply with instruction and this may provide a valuable insight into the motivations of those undertaking treatment. As someone who has endured many months of various elastic configurations, I feel the responsibility lies with both the orthodontist to effectively engage with the patient and with the patient to understand from the outset that treatment is not a passive activity but one where full cooperation is required.

  7. Vicki Vlaskalic says:

    Thanks Kevin and co-bloggers. Wondering what readers think about “Dental Monitoring” – the ability to monitor tooth movement change remotely via patient 3 second video taken on patients smart phone? (yes, I f they cant be bothered to take a 3 second video, we can be pretty sure they are not being compliant..) It has recently hit our shores in Aus, I believe it has been available to you in EU for some time. While it may be early days, (algorithms likely need validating and I am not sure that the major sales attraction – saving clinician and patient appointment time – will ultimately even be the largest pearl in this product), I can personally see much potential particularly with respect to clinical research. At Melbourne uni we are using it to evaluate retainer systems and occlusal change. This team knows how far and how “fast” teeth are moving between appointments and in retention, at intervals between 2 weeks to many months, with any appliance type, in thousands of patients. I cant wait until they data mine and we may be able to obtain real-time data on movement for individuals and over mega samples. I may study the change in tooth movement when I use different colour elastomerics versus NiTi, when a patient moves aligners every 2 weeks versus 1 week, with or without vibration or any other mechanical choice that I may have. I hope to make treatment decisions based not just on my philosophy or anecdotal data, but directly based on my patients individual response to what I am doing. No more ‘1mm per month” average, we all know its different for incisors, molars, young, elderly, medicated etc; now I hope to know exactly!……OK so fellow Kevin bloggers, am I too optimistic about this tool that I feel has enormous potential (and that I have no financial interest in )? Again, my interest has peaked due to the possibility of accurately and efficiently recording and measuring clinical change allowing me to evaluate and modify my mechanical protocols at the time of treatment; rather than the likely more popular attraction of practice efficiency. Whatever rocks your boat. But the conversation above makes me realize that we are still starved for knowledge and methods to obtain it once patients walk out of our doors – where patient cooperation and individual response to appliance activation is concerned. Kevin – can you look into this for us, please! VV

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