Perception and Practice of Nepalese Adult and Adolescent Patients towards Orthodontic Treatment

Proffit further classified adult orthodontic patients as younger adults and older adults. Younger adults are under 35 years of age; often in 20’s; and older adults are between 40’s and 50’s. Younger adults like adolescent patients generally go for comprehensive orthodontic treatment with esthetic and functional treatment goals, while older adults generally undergo adjunctive orthodontic treatment as a part of restorative or periodontal treatment plan.3


INTRODUCTION
World Health Organization defines an adult as a person older than 19 years of age unless national law defines a person as being an adult at an earlier age.An adolescent is a person aged 10 to19 years inclusive. 1According to the Labour Act of Nepal (1992); 'adult' means a person who is above the age of 18 years. 2offit further classified adult orthodontic patients as younger adults and older adults.Younger adults are under 35 years of age; often in 20's; and older adults are between 40's and 50's.Younger adults like adolescent patients generally go for comprehensive orthodontic treatment with esthetic and functional treatment goals, while older adults generally undergo adjunctive orthodontic treatment as a part of restorative or periodontal treatment plan. 3aditionally, orthodontic service is rendered to adolescents.In recent years, the ratio of adults seeking orthodontic treatment is in rise.According to Keith and Gootleib; the percentage of adult patients has raised from 3% in 1970 to 19% in 2003.After 1990's decade, adult orthodontic patients raised remarkably up to 25% in USA. 4 According to the survey

Patients towards Orthodontic Treatment
Research Article by American Association of Orthodontists; the number of adult patients increased by 14% from 2010 to 2012. 5 In Nepal, the percentage of adult orthodontic patient accounts up to 23%. 6 Prevalence of malocclusion is more or less same in adults as in adolescents.Various reasons have been cited by various authors for the rise in the number of adult orthodontic patients.The advancement in appliance design and techniques led to the development of esthetic and tooth colored brackets, which appealed adult patients.On the other hand, orthognathic surgery could treat many adult patients with dentofacial skeletal discrepancies; which yielded them fast and dramatic results.In present days; increased public awareness and media have led to the esthetic consciousness in the society, which has created social acceptance of the braces.The internal and external motivation from oneself, family and peers have contributed to the rising number of adult orthodontic patients.Moreover, there is economic independence with the adult people; who can pay of their own without relying on parents or others; and fulfill their childhood desire of wearing braces which could never be materialized before.The objective of the present study was to assess the perception and practice of adult and adolescent Nepalese orthodontic patients about ongoing orthodontic treatment and compare the findings between them.

MATERIALS AND METHOD
The perception and practice of Nepalese orthodontic patients were assessed using a self-administered questionnaire.The The study was based on structured questionnaire comprising of five questions each on perception and practice referring to Orthodontic Attitude Questionnaire. 8The reliability of the questionnaire was pretested on 50 samples.The perception

RESULT
The distribution of respondents in the present study is given in  6.1% adolescent and 11.3% adult orthodontic patients usually take analgesics to alleviate orthodontic pain (Table 3).The level of perception in both adolescent and adult patients were similar for study variables 'orthodontist's dealing', 'orthodontist's skill', 'chances of relapse' and 'treatment cost'.However, there was difference of perception about 'duration of treatment' between adolescent and adult; the level of perception was poor in adolescent and moderate in adult patients.
The level of practice of adolescent and adult patients were similar for study variable 'regular brushing', 'use of special cleansing aids', 'carelessness on appliance breakage', and 'use of pain-killers'.There was difference in level of practice on 'food restriction'; the level of practice was moderate in adolescent and good in adult patients (Table 4).
There was statistically significant difference in perception on study variables 'duration of treatment' and 'chances of relapse', and in practice on 'food restriction' and 'carelessness on appliance breakage' between adolescent and adult orthodontic patients (Table 4).

DISCUSSION
There are various differences between adult and adolescent orthodontic patients; the growth potential is significant in adolescent; whereas there is no growth potential in adults.
Hence growth modification is possible with adolescent, whereas orthognathic surgery is required to treat skeletal descrepancies in adults.The orthodontic treatment goal is generally idealistic in adolescent while the treatment goal is realistic in adults.
Various treatment considerations should be made while treating adult orthodontic patients; such as: biological, biomechanical, pharmacological, periodontal etc.General and oral health conditions are major concern in adult orthodontic patients.Systemic, metabolic, renal and liver diseases can affect orthodontic tooth movement (OTM).
Osteoporosis affecting Vitamin D/ Calcium metabolism can complicate OTM and uncontrolled diabetes affect periodontal health, causing alveolar bone loss. 9,10ny studies cited difference in practice management in treating adolescent and adult patients.Cooperation and compliance are normally considered better with adult patients.Generally they present good appreciation to the operator, but usually demand high expectations of treatment outcome. 11,12,13A study on Chinese adult orthodontic patients reported the improvement in patients' esthetics, self-confidence and self-esteem following the treatment. 14cording to the present study; in all issues adults had better perception about ongoing orthodontic treatment.The patents were satisfied with orthodontist's dealing and skill; except for cost of the treatment.More number of adult patients felt that the orthodontic treatment is expensive; it could be because of the reason that adult patient pay the treatment bill of their own.Also, adults had better level of practice on oral hygiene and appliance maintenance compared to the adolescent.
Similar study on Nepalese orthodontic patients showed good knowledge and practice related to orthodontic treatment but lacked good attitude. 15nerally, adults have low pain threshold, they might take more time to adjust the appliance; requiring more use of analgesics.Another report suggest that the adolescents are more vulnerable to undesirable pain due to orthodontic treatment. 16Report of the present study suggests that adult patients consume more analgesics (11.3%) as compared to adolescent patients (6.1%).Another study suggests that, the level of anticipated pain before orthodontic treatment is higher than the real pain experienced after orthodontic procedures in Nepalese patients. 17ny studies report longer treatment duration in adults. 18,19e reasons cited to be because of decreased vascularity study was conducted at seven orthodontic departments/ centers of Kathmandu and one in Dhulikhel.The sample size was calculated based on the prevalence of orthodontic problem of the Nepalese sample; which was calculated to be 395 (including 10% permissible error).A total of 536 orthodontic patients including 240 adults and 296 adolescents responded in the study.The age of the adult patient was determined as 20 years and above, and age of the adolescent patient was determined as 10-19 years according to the WHO criteria.1The study was conducted among patients undergoing comprehensive orthodontic treatment using fixed appliance for at least six months duration.The study was conducted during October 2013 -March 2014, after receiving permission from Institutional Review Committee and informed consent from respective orthodontic departments and the respondents.

Table 3 : Distribution of patients towards perception and practice of orthodontic treatment
Shrestha RM, Shrestha S: Perception and Practice of Nepalese Adult and Adolescent Patients towards Orthodontic Treatment Positively formulated (+), neutral (±), negatively formulated (-)

Table 4 : Difference between adolescent and adult patients towards perception and practice of orthodontic treatment Question Adolescent Adult
20restha RM, Shrestha S: Perception and Practice of Nepalese Adult and Adolescent Patients towards Orthodontic Treatment and low cellular response for OTM.20However, duration in many adult orthodontic cases can be lesser because of their Nepalese orthodontic patients possess good perception about orthodontist's dealing and skill, and good practice on regular brushing habits.Adolescent patients lack positive perception about duration of treatment and majority of patients feel that orthodontic treatment is expensive.Adult patients have better perception and practice about the orthodontic treatment than adolescent in all parameters studied except for 'cost of treatment' and 'use of analgesics'.It could be a matter of concern to practicing orthodontists that more than 25% patients are careless about their appliance breakage and about same number of patients consume analgesics for orthodontic pain.ACKNOWLEDGEMENTAuthors would like to thank Dr Prakash Bhattarai, Dr Anjana Rajbhandari, Dr Jyoti Dhakal, Dr Dashrath Kafle, Dr Manish Bajracharya, Dr Ujjwal Pyakurel for their cooperation in data collection.Also, we appreciate orthodontic departments and their patients of 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 for allowing us to conduct the studies