Knowledge, attitude and practice of patients towards orthodontic treatment

Malocclusion is a relatively common oral health problem that can adversely affect an individual’s quality of life as it influences not only oro-facial functions such as mastication, speech and swallowing, but also exerts some amount of psycho-social effect due to its impact on aesthetics [1]. A recent systematic review and meta-analysis on the prevalence of malocclusion in children and adolescents concluded that the worldwide prevalence was around 56% [2]. In Malaysia, it has been found that around 30% of children are in need of orthodontic treatment [3]. Patients usually seek orthodontic treatment to improve either their aesthetics or oral function such as masticatory efficiency [4‐6].

The success of orthodontic treatment depends on a multitude of factors related to patient compliance, such as attending appointments, maintaining good oral hygiene and limiting breakages of appliance [7, 8]. Patients who have had previous orthodontic treatment and parents who themselves have had orthodontic treatment tend to have better attitude towards orthodontic treatment [9]. Studies have illustrated that patients with better knowledge of orthodontics have improved attitudes towards orthodontic treatment thus increasing the likelihood of improved clinical outcome [10, 11].

The responsibility of assessing patient compliance and imparting the necessary knowledge to patients before and throughout the entire course of the orthodontic treatment usually falls on the shoulder of the orthodontist and orthodontic team. Having prior information on the knowledge, attitude and practice (KAP) of patients can be extremely useful in aiding the orthodontist in not only estimating a patient’s compliance level but also in formulating strategies to improve patient compliance which may in turn improve clinical outcomes.

Though such studies have been conducted in other parts of the world to assess the level of knowledge, attitude and practice in orthodontic patients, they are few and far between [12‐14]. Most of these studies found that the majority of orthodontic patients possess good knowledge of orthodontic treatment but were lacking with regard to attitude and practice. There is a lack of such studies in the Malaysian setting. As such, the aim of our study was to evaluate knowledge, attitude and practices of the patient towards orthodontic treatment in a Malaysian population and to compare and contrast our findings with those from the rest of the world.

A total of 507 respondents with a mean age of 22.5 years (SD ± 2.8) participated in this study. The socio-demographic features of the respondents are shown in Table 1. Briefly, participants were predominantly female (64.1%) and majority of respondents were from the Malay ethnic group (62.3%). Almost two-thirds of respondents (74.3%) had tertiary education. Most respondents were from the lowest income bracket or B40 group (71%), followed by 23.7% of respondents from the middle-income bracket (M40 group) and only 5.3% of respondents were from the highest income group (T20 group).

Health-related behaviour (also known as health behaviour) has been shown to directly and indirectly affect an individual’s health either in a positive or negative manner. Knowledge, attitude and practice (KAP) is an essential component of an individual’s health behaviour. Despite its importance, there is a scarcity of health behaviour research especially regarding the KAP of orthodontic patients. Most studies have focused on the “awareness” component of health behaviour. From the perspective of orthodontics, health behaviour may affect clinical outcome due to its influence on attitude and practices related to the patient’s role in successful orthodontic treatment.

The majority of patients in our study were females. This may be due to the generally higher level of awareness related to treatment need as well as demand among females [4, 16]. Overall, females were found to have better levels of KAP and this finding is similar to other KAP studies [13, 14]. In our cohort, statistically significant differences between the two sexes were observed in relation to knowledge on retainer wear, the attractiveness when wearing braces, usage of cleaning aids and remembering as well as attending appointments regularly; with females doing better than males.

The ethnic distribution of the patients in this cohort was reflective of the overall ethnic distribution of the Malaysian population based on the estimates by the Department of Statistics Malaysia [17].

The government or public healthcare system in Malaysia is utilised by all layers of society cutting across all income brackets and this is illustrated in the findings from our study. Interestingly, the vast majority of patients in our cohort were from the B40 household income group. This suggests that patients from the B40 income were also very cognizant of orthodontic treatment needs. Due to the highly subsidized cost of orthodontic treatment in the public health sector, patients from the B40 income group are also able to afford orthodontic treatment. This may be the reason why most respondents felt that orthodontic treatment provided at the public healthcare facilities was inexpensive. However, as there is an extremely high demand, there exists a long wait list. A staggered payment system for the lower income patients has recently been introduced to help ease the burden of payment for some. Suggestion of a tiered payment system where the poor receive a larger subsidized rate than the rich could encourage those from the lower income bracket to seek treatment.

Our study found that overall, most patients had good knowledge of orthodontic treatment however the percentage of positive attitude and orthodontic treatment related practices section were lower. Being aware of the patient’s level of knowledge, attitude and their orthodontic related practices can help the clinician better understand our patients and our role as a clinician. This also enables the orthodontic team to reflect on the areas that we could pay a closer attention to when educating our patients in an orthodontic practice.

In the knowledge section the lowest level of knowledge (69.4%) was regarding the consequences of incomplete orthodontic treatment and this level was much lower than other similar studies which found the level to be somewhere between 79.0% to 90.1% [12‐14]. This is an indication that the orthodontic team should include and stress upon the possible risks of incomplete orthodontic treatment during the discussion of the treatment plan with the patients so that the patient is fully aware of consequences and the possibility that dental condition may worsen over time if their orthodontic treatment is not completed.

As for retainer wear, most studies tend to focus on patient compliance, the length of retainer wear and the type of retainer prescribed [18‐22]. Not many studies have been carried out on the knowledge of retainer wear among orthodontic patients. A previous study showed that the level of knowledge regarding retainer wear upon completion of treatment can vary from as low as 45.7% to as high as 79.9% [13, 14]. Our study however found that a high percentage 80.9% of patients were aware of the need to wear retainers which shows that we have been successful in communicating the need for a retention phase to the patients. The awareness on the need for retainer wear upon completion of the active orthodontic treatment cannot be stressed enough and is vital in the overall maintenance of successful orthodontic treatment.

Generally, the respondents had a positive attitude towards their orthodontic treatment experience except where the waiting time to see the orthodontist at every appointment was concerned. We found that a large number of patients 64.7% felt that they wait too long to see their attending orthodontist. Previous studies have found that waiting time is the single most important factor contributing to patient satisfaction and on whether the patient is likely to be compliant for the following visits [23, 24]. As orthodontic treatment requires multiple visits, compliance is a very important factor in determining a successful treatment outcome. An efficient system should be implemented to reduce the waiting time for patients. A good way to decrease the waiting time is using a staggered appointment system. Frequent breakages usually lead to emergency appointments resulting in delays that may negatively affect the appointment / waiting time (as well as duration) of other patients that have been given appointments for that particular day. Reducing breakages will allow the orthodontist to better predict the time needed to see each patient and in turn avoid overrunning the appointment time. However, for this to work the orthodontist needs to keep strictly to time and the patient too needs to adhere strictly to their appointed time and minimize breakages; patient education is integral. Interventions such as videos, magazines, health talks, visual art and information by oral health personnel in the waiting area have proven to reduce the waiting stress and to improve the waiting experience [23]. Attitude can be moulded prior to starting the treatment and during the initial visits as well as during the bond up appointment through chair side instructions and handing out the relevant patient information sheets. Studies have shown that patients who have had previous orthodontic treatment [8, 9, 25] and those whose parents have had orthodontic treatment were more likely to have a positive attitude towards orthodontic treatment [26]. Though pain was not assessed in this study, the experience of pain is thought to be an important factor that can influence the patient’s attitude towards orthodontic treatment [7, 27, 28].

Despite patients having good knowledge regarding orthodontic treatment, orthodontic treatment related practices of patients in general were at a much lower level. Oral hygiene practices are a very important part of orthodontic treatment to prevent development of oral diseases during orthodontic treatment [29]. Frequent reinforcement of oral hygiene and motivation not just at the initial stages of orthodontic treatment but throughout the treatment should be carried out as it has been shown to improve patients’ attitude and oral hygiene practices [30, 31]. Some studies show that a leaflet and other promotional materials can also help to improve the patients understanding and oral hygiene practices [32]. The failure to alter dietary habits can directly lead to a high number of breakages. As such, more effort needs to be placed on emphasizing the importance of avoiding hard, sticky and large mouthfuls throughout the treatment duration to reduce breakages and to reduce emergency appointments that in turn may further burden the long waiting time of patients.

In this study only slightly more than half the respondents made use of special cleaning aids. We found a large variation in the usage of special cleaning aids within the existing literature, ranging from 25.3 to 100% [33‐35]. Although this is an area of interest, the current study was not designed to look at the reasons behind this poor orthodontic treatment related behaviour. Studies looking into this particular aspect of orthodontic treatment related behaviour are very much needed to better understand the patient’s perspective and to enable remedial measures to be put into place. Good oral hygiene practices and regular fluoride application are important during the fixed appliance stage as fixed appliance can easily trap food and harbour plaque which can lead to patient developing gingivitis, periodontitis, dental caries and halitosis.

As the orthodontist sees their patients frequently and on a regular interval for a number of years, their ability to give good oral health education can influence healthy oral health practice in the patient. Hence, more attention needs to be given to the patients especially after their initial bond-up appointment to encourage patients to use recommended cleaning aids. Periodic reinforcement of brushing instructions and dietary restrictions during the follow-up appointments are important to improve patient’s practices. Giving appropriate and adequate information, repeated motivation and practice to patients has been shown to change the patient’s attitude and practice to a more positive one [36]. A good orthodontist-patient relationship can also improve the patient’s attitude and compliance towards treatment [37, 38].

There were several limitations to our study. The personality traits of patients were not looked at although they could be a contributing factor to their attitude. Reasons for the patient’s poor orthodontic related practices were also not investigated in this study as this was beyond the scope of the study. This study was also focused on those undergoing only fixed appliance therapy, as inclusion of other treatment measures would make the population too heterogenous. We were also unable to do a sub-analysis assessing the relationship between KAP and time to treatment onset. However. this is something we plan to look at during future studies.

Several interesting features regarding the KAP of patients in relation to their orthodontic treatment were discovered through this study. Even though a large majority of patients were found to have good knowledge but attitude towards orthodontic treatment and orthodontic treatment related practices were not as good. The orthodontics related practice with the lowest score was related to patients not strictly adhering to dietary restrictions during their orthodontic treatment. The level of usage of special cleaning aids and the frequency of breakages were also aspects that need to be improved. The orthodontic team can play a more active role in improving orthodontics related practices among patients through better patient education.