Knowledge , Attitude and Practice of Patients towards Orthodontic Treatment : A Multi-centric Study

Social psychologists have described various theories on patient compliance. Many components of ‘Health Belief Model’ are applicable to orthodontic treatment situation. Variables like treatment-seeking behavior, personality type and barriers to action comply well with the compliance of the patient.1,2 A compliant orthodontic patient may be described as a patient who practices good oral hygiene, follows appropriate diet, maintains appliance without breaking, keeps regular appointments, and follows instructions of the doctor. The cooperation of the patient helps in achieving treatment goal more expeditiously. The compliant patient may be identified by personal and demographic characteristics such as; age, sex, personality type, social class etc. Since sex is an imperative attribute variable, it is frequently reported in many studies.3-6


IntroductIon
Social psychologists have described various theories on patient compliance.Many components of 'Health Belief Model' are applicable to orthodontic treatment situation.Variables like treatment-seeking behavior, personality type and barriers to action comply well with the compliance of the patient. 1,2 compliant orthodontic patient may be described as a patient who practices good oral hygiene, follows appropriate diet, maintains appliance without breaking, keeps regular appointments, and follows instructions of the doctor.The cooperation of the patient helps in achieving treatment goal more expeditiously.The compliant patient may be identified by personal and demographic characteristics such as; age, sex, personality type, social class etc.[5][6] The knowledge, attitude and practice (KAP) study explores changes in knowledge, attitude and practice of the target group with respect to predetermined domain.The KAP study serves as an assessment tool to measure information, perspective, and performance of any desired task of the community.It enables the efficient process of evaluation; The study is based on structured questionnaire referring to Dental Attitude Questionnaire. 9,10The questionnaire was modified as per the Nepalese context.The questionnaire comprised of fifteen questions in three sections on knowledge, attitude and practice with five questions each.The reliability of the questionnaire was pretested on 50 samples.

Orthodontic
The knowledge of the patients about orthodontic treatment was assessed on binary scale of agreement or disagreement.It comprised of five common facts related to orthodontic treatment, like: 'purpose of braces (K1)', 'treatment duration (K2)', 'importance of following instructions (K3)', 'consequences of incomplete treatment (K4)', and 'wearing of retainer (K5)'.
The self-administered questionnaire was written in English; questions were explained whenever required.The data were entered according to patient's perception on their agreement, disagreement, or neutral position.For knowledge component, items were rescored so that the positively formulated perception was scored 1and negatively formulated perception was scored 2. For Attitude and Practice components; positively formulated perception was rescored 1, neutral perception was rescored 2 and negatively formulated perception was rescored 3. The scoring criteria and determination of level is depicted in Table 1.The difference in perception between female and male patients was tested using Mann-Whitney U test.The level of significance was adjusted at 0.05 at 95% confidence interval.The data were analyzed using SPSS software version 17.0.

result
The study found that, more than 85% of sample had knowledge on purpose of braces (K1) and treatment duration (K2).
More than 90% had knowledge on importance of following instructions (K3), and consequences of incomplete treatment (K4).However, only 45.7% patients had the information on wearing of retainer after completing the orthodontic treatment (K5) (Table 2).The analysis on attitude of patients towards orthodontic treatment showed that; 49.3% patients had positive attitude towards social esthetics on braces wearers i.e. they disagree that people wearing braces do not look good (A1).31.5% patients disagreed on long waiting time at waiting room (A2), 47.8% disagreed that time spend for orthodontic procedure during the appointment is inadequate (A3), and 82.2% patients are happy about treatment outcome so far (A4).68.5% patients feel cost of orthodontic treatment is expensive (A5) (Table 3).
Analysis on practice of patients showed that; 58.5% patients regularly restrict hard food and alter dietary habits (P1), 82.3% brush and rinse mouth more carefully (P2), and 39% use special cleaning aids (P3).Contrarily; 28.9% admit that brackets or wires usually break due to their carelessness (P4) and 12.7% often forget appointment dates (P5) (Table 4).*positively formulated (+), neutral (±), negative (-) Table 5 portrays scoring of the knowledge, attitude and practice components and determination of level.Nepalese orthodontic patients possessed good level of all components of knowledge about orthodontic treatment except retainers.Knowledge on wearing of retainers was good among females but poor among male and total sample.The attitude of orthodontic patients on satisfaction on treatment outcome was good.Attitude on social aesthetics of braces wearers, time spend for orthodontic procedure and waiting time were moderate.The attitude of male patients about waiting time and attitude of all subjects on cost of orthodontic treatment were poor.The practice of orthodontic patients on food restriction, oral hygiene maintenance and regularity of appointment were good and practice on use of special cleaning aids and carefulness on appliance were moderate.
The statistical analysis showed significant difference between female and male patients on knowledge on duration of orthodontic treatment (K2) and wearing of retainers (K5), attitude on cost of orthodontic treatment (A5) and in practice of brush and rinse mouth more carefully (P2) (Table 6).4][5][6] The present study showed similar finding in many parameters that female Nepalese patients possessed better understanding and perceptions towards ongoing orthodontic treatment.The orthodontically treated subjects' attitude towards the satisfaction with treatment result and experiences with follow-up appointments were good. 10It is assumed that the general public have positive attitude towards orthodontic profession; 15,16 parents who were former orthodontic patients are more likely to approve their child for orthodontic treatment. 17 OJN Journal of Nepal, Vol. 4, No. 1, June 2014 The study was conducted at various orthodontic treatment centers offering exclusive orthodontic service of qualified specialists; viz: Kantipur Dental College & Hospital, People's Dental College & Hospital, Kathmandu University School of Medical Sciences-Dhulikhel Hospital, Samaj Dental Hospital, Mero Dental Hospital, The Orthodontic Center, Dental Arch Clinic and Dental Square Clinic.The study was conducted during September 2013 -February 2014.

dIscussIon
Egolf et al11 studied factors like belief, attitude, perceptions, and reasons thought to be associated with compliance.They considered these factors as combination of personality type, negative motives (pain, inconvenience, dysfunction) and positive motives (health awareness, specific dental knowledge, personal oral embarrassment).A study by Bos et al 12 however, did not find correlation between compliance and satisfaction among orthodontic patients.The present study assessed information of the patient on orthodontic treatment required for its compliance and maintenance.The assessment on attitude of the patient was related to perception on treatment service and cost, and questions on practice were related to oral hygiene methods and carefulness of the patient.The present study did not assess the barriers to action, as the questions were not targeted at the reasons for non-cooperation.The study also did not consider patient's pain perception and inconvenience due to braces.The study on pain experience during orthodontic treatment among Nepalese patients was analyzed by Kafle and Rajbhandari.13

Siddegowda and Rani 14
found moderate level of knowledge and awareness about orthodontist and irregular teeth, and less awareness about orthodontic treatment among Indian school children through an epidemiological survey.Bos et al found significantly positive attitude towards orthodontists in previously treated subjects compared to untreated ones.

, 18 It
is satisfactory to learn that Nepalese orthodontic patients possess good level of knowledge about orthodontic treatment.However, only 45.7% patients had the information about wearing of retainer.This fact would lead to difficulty in prescribing the retainers after the treatment and jeopardize the stability of results.The practice of orthodontic patients on oral hygiene, food restriction, and regularity of appointment were good; however use of special cleaning aids was moderate.The present report on oral hygiene maintenance of Nepalese orthodontic patients is consistent with the previous study on same population.19These information are pertinent for better clinical management for service providers.It can help improve their service and enhance rapport with the patients.Actually, orthodontist's interpersonal behavior and role in patient motivation is another aspect of successful orthodontic treatment.The orthodontist should give positive feedback and communicate with the patient on the issues of patient cooperation and their inconveniences.Orthodontists should explain about the appliance including retainers, and advice on oral hygiene, dietary control and appliance maintenance methods.Patients who are dissatisfied with the treatment and interpersonal aspects tend to avoid care and jeopardize the name, and fame of the orthodontic practice and the practitioner.conclusIon Nepalese orthodontic patients possess good level of knowledge about orthodontic treatment, but had poor information about the retainers.About half the number of patient thinks that wearing the braces do not look good, however more than 80% patients are happy about the treatment outcome.In general, the attitude of orthodontic patients towards ongoing orthodontic treatment is moderate, and two third of the patients think that orthodontic treatment is expensive.Although the orthodontic patients practice good oral hygiene, food restriction and regular appointment; they are only moderately careful about the appliance breakage.Despite having good knowledge on orthodontic treatment, patient's attitude and practice towards orthodontic treatment is mostly moderate.It is important for practicing orthodontists to inform patients about the retainers, appliance maintenance and build inter-personal rapport with the patients.The practitioners shall improve the patient attitude by shortening the waiting time of patients at waiting room, adequately spend time on procedure and charge the treatment cost more reasonably.acKnoWledgeMentWe would like to thank Dr Anjana Rajbhandari, Dr Dashrath Kafle, Dr Manish Bajracharya for their cooperation in data collection and all orthodontic patients who participated in the study.

table 1 : scoring criteria score level score level score level
Shrestha RM, Bhattarai P, Dhakal J, Shrestha S: Knowledge, Attitude and Practice of Patients towards Orthodontic Treatment: A Multi-centric Study

table 3 : distribution of patients according to their attitude on orthodontic treatment
Shrestha RM, Bhattarai P, Dhakal J, Shrestha S: Knowledge, Attitude and Practice of Patients towards Orthodontic Treatment: A Multi-centric Study

table 6 : Mann-Whitney u test statistics to assess the difference between female and male subjects total Female Male p-Value Mean sd Mean sd Mean sd
RM, Bhattarai P, Dhakal J, Shrestha S: Knowledge, Attitude and Practice of Patients towards Orthodontic Treatment: A Multi-centric Study *Statistically significant at p < 0.05 Shrestha