What do our patients think about the benefits of orthodontic treatment?
I am genuinely surprised and disappointed that a large amount of research has been done into attempting to identify the benefits of orthodontic treatment. Yet, we lack reliable evidence about these benefits. This new study provides us with useful information.
Over the past 40 years, there have been many studies that have attempted to identify the benefits of orthodontic treatment. Unfortunately, these studies have had significant flaws in the design and their findings are not useful. Furthermore, the investigators have used outcome measures such as cephalometrics and occlusal indices. These are only relevant to orthodontists and not to our patients. I was, therefore, really interested to see this new study that used a qualitative approach to find out patients views on the benefits of their treatment.
A few weeks ago I posted about a qualitative study into factors that influenced Twin Block wear. I explained how this relatively new technique for orthodontics is likely to be very useful, as our research moves towards more complex treatment effects. 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.
A team from the sophisticated City of London did this study. The EJO published the paper.
What did they ask?
They wanted to find out.
“What do our patients feel about the effects of their treatment”?
What did they do?
They did a cross-sectional qualitative study. The study team asked patients who were between 13 and 18 years old at the end of their comprehensive orthodontic treatment to take part in the study. They used a technique called purposive sampling. This is when the investigators identify a broad set of inclusion criteria and look for participants with these characteristics. In this study, the main inclusion criteria were gender, ethnicity, type of malocclusion and time since the removal of appliances.
The next stage was to carry out semi-structured 1:1 interviews using a pre-prepared topic guide. They continued to interview participants until the primary responses or themes began to repeat. This is called the saturation point.
They recorded and transcribed the interviews. Then the three members of the study team then read the transcripts to identify the main themes using a technique called thematic analysis using a framework approach. I am not too familiar with this, but I think that this allows the team to identify and extract the main perceptions of the participants.
If you are wondering if this is very soft data, then I agree, but it is a good way of gathering the information that is relevant to patients. However, I appreciate that orthodontists who like “hard data” will struggle with this approach.
What did they find?
They provided a large amount of information in the form of narrative. I do not have the space to go through this all. But, I have tried to identify the main points.
They interviewed 8 males and 12 females. The main themes that were related to the outcomes were
- Health-related behaviour change
- Dental Health
- Psychological influences
These had several sub-themes, and they used direct quotes to illustrate their findings.
Health-related behaviour change.
Most of the participants reported an increased awareness of oral hygiene and the need to improve their diet after treatment.
” I’m more aware of cleaning and the hygiene of teeth now that I’ve been through treatment. Like, because my teeth are more straight, I feel I need to take care of them. I’ve been through years of treatment, I shouldn’t let it go to waste”.
An important theme was their perceived improvement in dental and facial aesthetics. They also reported improved function and less food trapping and plaque retention.
“I’m really happy now that I’ve got them done, they look so much better . . . imagine if I had to go the rest of my life with my teeth how they looked before, I really hated them”.
This was associated with their appearance when they smiled, feeling more comfortable when they looked in a mirror or having photographs taken. This was particularly relevant when they considered the influence of social media.
“I started smiling more with my teeth . . . when I take photos, I smile all the time in them, like on Instagram and stuff and most of my photos are with my mouth open”.
They also reported increased self-esteem and confidence, increased acceptance and improved social interactions.
“The best thing is more confidence. . . . I don’t have to be ashamed of my teeth. It makes me feel better about myself”.
Their overall conclusion was that they found real and essential benefits and these are important for both orthodontists and patients to know.
What did I think?
I have to admit that I am an “old school” orthodontic researcher and I tend to find these papers challenging to read and understand because their data does not contain numbers. However, the more qualitative research that I read, I become more receptive to this methodology and its results. Indeed, if I were starting my research career again, I would be using this approach. This is because it aims to gather essential outcomes for us, as we move away from orthodontist’s values. I certainly hope that qualitative techniques will allow us to identify the main results of orthodontic treatment, which is something that we have failed to do, up until now.
They followed standard qualitative techniques, and the paper was nicely written. I particularly liked the use of the patient’s quotes.
I thought that their findings were logical and clear. I recommend that all readers of this blog have a look at this paper if they can get through the EJO firewall!
My final thought is that I hope this line of research can be adopted widely and we will, at last, be successful in finding out more about the real effects and value of orthodontic treatment.
Funding this blog
Finally, I would like to thank all the readers who made a donation to fund my blog for another year. It was great to see that the target amount was hit within two weeks. This will pay for the servers, email lists and the other incidental software costs that running the blog involves. I will leave the donation button working in the sidebar for a couple of months, to pay for any contingencies that may arise. The next campaign for running costs will start in April 2020. Thanks for all your support.
Emeritus Professor of Orthodontics, University of Manchester, UK.