Orthodontic patients do not wear headgear!
A fair proportion of orthodontists still use headgear. This blog post is about how much co-operation we can expect using this treatment.
I stopped using headgear many years ago. This was because I was not sure whether my patients were wearing it. I do also wonder if I got such low co-operation because I did not really believe that they were going to wear this type of appliance, and the self-fulfilling prophecy occurred. Putting my deficiencies as a headgear orthodontist aside. It is clear that headgear wear requires considerable co-operation. Some of us have wasted a fair amount of time on headgear charts to record headgear wear. (My patients did not bring theirs back, or it was clear that they had completed them the day before!). But now we have headgear timers to help us calculate headgear wear. This new paper reports on a study that looked at headgear compliance in a group of Swiss orthodontic patients.
The author has also included a pdf of this paper on Research Gate
In the literature review, they pointed out that 62% of the USA and Canadian orthodontists use headgear according to a survey published in 2016.
What did they ask?
They asked this simple question.
“What is the patient compliance in headgear wear over 8 months”?
What did they do?
They did a straightforward prospective cohort study. The PICO was
Participants: 8-12-year-old children with Class II malocclusion (OJ>6mm)
Intervention: Orthodontic headgear
Outcome: Hours and days of wear.
They enrolled 20 children into the study and asked them to wear their headgear for a minimum of 12 hours a day.
They measured the amount of headgear wear using a temperature and force sensitive timer. They saw the patients every month. The patients were aware that their treatment was being monitored.
At the end of the 9 months, they calculated the number of days that the patients used the headgear, the number of hours per day and percentage compliance.
What did they find?
All the patients completed the study. These were the main findings.
- The mean duration of treatment was 8.3 months.
- Actual headgear wear (at least once per day) was 5.8 months (70% of the time)
- Average daily wear was 6.4 hours (54% of the 12 hours requested). This included the days of no wear.
When they looked at the wear during times of the day. They found:
- During the night from 24.00 to 07.00 there was average compliance of 50%
- During the day (11.00-20.00), the compliance was zero.
- Compliance during the summer was particularly low.
Their overall conclusion was that compliance with headgear was poor.
What did I think?
I thought that this was a fascinating and straightforward study that answered a clinically relevant question. You may feel that the results are nothing new, however, the low amount of co-operation surprised me.
I felt that the good points were that it was a prospective study, and all the patients completed the data collection period. The data were analysed in a simple and set out in a set of nice descriptives. Importantly, the investigators did not over-analyse the data. I also thought that their findings were clinically relevant.
I looked carefully at the limitations of the study. The first is that the patients knew that they were being monitored. This means that the study is susceptible to the Hawthorne Effect. As a result, they may have worn their headgear for longer than they would under “unmonitored” conditions. However, the findings are relevant to patients who are being watched.
Some may feel that the sample size was low, and they did not do a sample size calculation. However, this is a descriptive study, and the results do appear to have some validity because they are similar to other studies.
It is also interesting to see that these results are similar to other studies using timers in Twin Block appliances.
I think that there are several clinical implications. Firstly, should we just “give up” on headgear and consider other methods of applying distal force? Indeed, the advent of alternative anchorage solutions from TADs has considerable advantages.
We also need to consider whether this limited wear has resulted in clinically meaningful change to the molars. This data is part of a larger clinical trial with a control group, and we will find out the answer to this question in due course. I look forward to seeing this paper.
It is nice to see a simple clinical study with straightforward, clinically relevant results. I thought that this was great.
Emeritus Professor of Orthodontics, University of Manchester, UK.