Why don’t patients wear their Twin Blocks?

We do not really know why some of our patients wear their Twin Blocks and why some do not manage to co-operate. This new paper gives us useful information. A few weeks ago I posted about a great study that used timers to measure co-operation with the Twin Block appliance.  The authors also did additional research to find out what influenced the patients to co-operate with treatment.  I thought that this was really interesting as it provided us with a lot of clinically relevant information. A team from Barts and the London Dental School, in the beautiful South of England, did this study. The AJO-DDO published it.

They wrote an excellent introduction on factors that influence compliance with removable orthodontic appliances.  The noncompliance rates with Twin Blocks are between 10-49%.  But, we all think that our own patients are better than the average!  It is also clear that patients tend to overestimate their individual compliance rates. In this respect, their study using timers can provide us with great information, and they decided to carry out this further study on their sample.

What did they ask?

They asked:

What are the factors associated with different levels of compliance with the Twin Block appliance? Can we obtain information that may be used to increase compliance?

What did they do?

They did a research project using qualitative methods.  This is a relatively new technique for orthodontic research, but it is becoming more popular. In effect, qualitative research involves interviewing people and then analysing the results in a standardised way. Its main advantage is that this method gathers opinions and feelings about treatment or its outcome.  As a result, the findings are very relevant to our patients. They took a sample of 22 patients who were taking part in the trial of full or part-time wear of Twin Blocks. They monitored the time that the appliances were being worn with the Theramon device.  The sample included a mixture of good and poor compliers. In the first stage of the study, they developed a topic guide that they used to structure the interviews.  They then carried out semi-structured interviews of the sample of patients. Each meeting lasted about 45 minutes. Finally, they transcribed the interviews, and the team analysed them using something called Framework methodology. I have been involved with this in some of our research, and this is a lengthy process of discussion and retesting that eventually identifies themes.

What did they find?

For most orthodontists, qualitative research is challenging to read and follow. I think that this is because we are used to numbers etc.  The results are presented as descriptives, and we also struggle with this.  I have tried to make this as simple as possible because of space constraints.  I feel that these are the relevant findings. They identified five main themes, these were:

• Self-motivation
• Social influence
• Quality of life impairment and adaptability
• Perceived treatment progress
• Pragmatic and recall issues.

They also divided these into enablers (influences positively) and barriers (influences negatively) and some could be both of these. I will look at some of these in more detail. Self-motivation clearly influenced the patients. They wanted to improve their appearance.  They also did not want to be different from other people their age.  However, the lack of self-motivation was a barrier to co-operation.

Social influences.

These included their parents, peers and the orthodontist. One crucial key to co-operation is the relationship between the patient and the orthodontist. The orthodontist needed to be supportive and informative.  This also relied on positive reinforcement from the operator.  Similar factors were reported for the influence of their parents. My interpretation of this was that being supportive was more important than taking a threatening stance when co-operation was not good.  Finally, the influence of their peers was very important. Their co-operation was influenced by positive and negative influences in the somewhat harsh life of the school and playground.

Quality of life impairment and adaptability.

This was crucial to co-operation and was concerned with how the patients overcame the hassle of wearing the Twin Block.  These included pain and teasing. These quotes are very relevant.

“I stopped wearing it because of the pain and the way that I spoke with it.” “No one could understand me, I just stayed quiet, and after a while, I just took it off”. “I got teased at first about my talking, but it stopped after a while”.

Perceived treatment progress.

They found that a positive attitude towards treatment progress was fundamental. The orthodontists pointed out the changes and the patients notice their appearance improving.

Pragmatic and recall issues

These were concerned with prescribed wear time, interference with daily activities and reminders.  These were all rather complex interactions and reflected the problems with the patients having an active life and having to adapt to wearing the appliance.

Improving compliance

Finally, the authors made some suggestions to improve compliance. These were:

• Effective communication between the orthodontist, their team and the patient.
• Modifying the appliance, by making the blocks smaller (but this may influence their effectiveness)
• Using reminders, for example, apps or text reminders.

What did I think?

I thought that this was a great piece of research that provided us with useful clinical information. While some of the findings reinforced my clinical impressions of the influences of co-operation, it also reminded me of the importance of explaining the treatment to the patient and parent.  I was also encouraged to see that they suggested using reminders and timers to improve co-operation.  I think that all those who treat patients with functional appliances should read this paper because it is full of exciting and relevant information. Some will feel that the findings are obvious, however, having positive reinforcement of our current practice is always useful.  We all like to know if we are doing the right thing.