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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 7  |  Issue : 4  |  Page : 182-186

Attitude of patients/parents with cleft lip and palate toward orthodontic treatment: A survey


1 Department of Orthodontics and Dentofacial Orthopedics, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Oral and Maxillofacial Surgery, Armed Forces Medical College, Pune, Maharashtra, India

Date of Submission23-May-2020
Date of Decision02-Jun-2020
Date of Acceptance07-Jun-2020
Date of Web Publication30-Nov-2020

Correspondence Address:
Shiv Shankar Agarwal
Department of Dental Surgery and Oral Health Sciences, Armed Forces Medical College, Pune, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdrr.jdrr_46_20

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  Abstract 


Background: Assessment of attitude among patients with cleft lip and palate (CLP) and their parents is vital for successful orthodontic treatment outcome. The study of variability of attitude toward orthodontic treatment among patients with CLP and non-CLP may reveal requirement of any additional care to the CLP patients. Materials and Methods: Part I of the study surveyed 50 CLP patients and their parents regarding their attitude toward orthodontic care. Part II of the study compared CLP patients with their non-CLP counterparts regarding attitude toward treatment duration, oral hygiene, dietary, and other difficulties faced during the treatment. Results: No difference in attitude toward requirement of orthodontic treatment and adequacy of number of appointments planned was observed between CLP patients and their parents (P > 0.05). The CLP parents showed a higher satisfaction with improvement in smile, overall looks, and changes in overall personality of their children (P < 0.05). Both CLP and non-CLP patients showed a similar experience with orthodontic treatment duration and difficulties experienced during treatment (P > 0.05). The CLP group had a higher difficulty in brushing with braces and required extra time for brushing than the non-CLP group (P < 0.05). Conclusions: Although the patients with CLP are emotionally comparable to their non-CLP counterparts, still special attention may be given to them during treatment because of low self-esteem secondary to impaired facial esthetics and difficulty in brushing and oral hygiene maintenance during treatment owing to various anatomical complexities in these patients.

Keywords: Attitude, cleft lip and palate patients, orthodontic treatment


How to cite this article:
Datana S, Agarwal SS, Bhandari S K, Sahoo N K. Attitude of patients/parents with cleft lip and palate toward orthodontic treatment: A survey. J Dent Res Rev 2020;7:182-6

How to cite this URL:
Datana S, Agarwal SS, Bhandari S K, Sahoo N K. Attitude of patients/parents with cleft lip and palate toward orthodontic treatment: A survey. J Dent Res Rev [serial online] 2020 [cited 2021 Jan 24];7:182-6. Available from: https://www.jdrr.org/text.asp?2020/7/4/182/302050




  Introduction Top


Orthodontic therapy not only brings about a positive impact on the facial appearance and smile esthetics of the patient but also affects social attributes such as self-belief, improved career opportunities, and confidence.[1],[2],[3] Various factors delaying orthodontic care to patients include paucity of information, cost factors, social factors related to wearing visible braces, anxiety/fear of pain, and also attitude toward treatment of both the parents and patients. A good knowledge of various patients' attributes affecting patient motivation and enhanced cooperation during orthodontic treatment is a prerequisite for a successful clinical practice. These attributes are, in turn, affected by the attitude and previous experience of the patient and parents toward orthodontic treatment. A strong correlation has been reported in orthodontic literature between the attitude of the patients/parents toward orthodontic therapy and perception of pain postinsertion of orthodontic appliances.[3],[4],[5],[6]

Various studies have reported that the patients with cleft lip and palate (CLP) are more conscious about their facial appearance and social acceptance/interactions than their non-CLP peers. The birth of a child with CLP has a negative social and psychological impact on the parents. The treatment of such children is usually of longer duration than their non-cleft counterparts. An active participation of the parents is required for successful treatment of such children.[7] Although majority of studies show a strong agreement between children with CLP and their parents pertaining to their treatment issues, a few disagreements have also between reported between the patients and their parents.[7],[8],[9] This may have an impact on outcome of the orthodontic treatment.

Therefore, the assessment of magnitude of child and parent agreement on orthodontic care and their attitude toward orthodontic treatment is imperative for the orthodontic team. These attributes as well as treatment experiences may be different in patients with CLP and non-CLP patients which require to be evaluated for differential care to these patients. Therefore, this questionnaire-based survey was conducted to assess the attitude toward orthodontic care of the patients with CLP and their parents so as to predict motivation and cooperation during treatment. A comparison of attitude between patients with CLP and non-CLP patients was also been done in this study to understand the variability of attitude toward orthodontic treatment in these patients.


  Materials and Methods Top


This questionnaire-based survey was conducted among patients with CLP and their parents and non-CLP patients undergoing orthodontic treatment at a tertiary care government teaching institute.

Inclusion criteria

  • CLP patients in the age group of 11–17 years undergoing orthodontic treatment with fixed appliances since >1 year at the institution
  • Non-CLP patients in the age group of 11–17 years undergoing orthodontic treatment with fixed appliances >1 year at the institution
  • Parents/guardians accompanying the patient volunteering to participate in the study and willing to fill the questionnaire on behalf of self/child patient
  • Absence of any associated syndrome or psychological problems in the patient/parents.


The study was approved by the institutional ethical committee. Written informed consent was obtained from the parents/guardians, and informed assent was taken from the patients before participating in the study. Those refusing to sign the written consent were excluded from the study. The questionnaire-based survey was carried out by two trained orthodontists. Separate interviews were carried out in the consultation room of the institute for both the parents and patients before distributing the questionnaires to educate them about the study. Assistance was provided in filling the questionnaire to the younger children and explained in both Hindi and English languages. The questionnaire was divided into two parts. Part I of the questionnaire was distributed to 50 patients with CLP and their parents. It included comparison of attitude between patients with CLP versus their parents toward orthodontic treatment progress and their experience with the orthodontist. Part II of the questionnaire was distributed to 50 patients with CLP and 50 non-CLP patients. It included comparison of attitude between patients with CLP versus their non-CLP counterparts regarding attitude toward treatment duration, oral hygiene, dietary, and other difficulties faced during the treatment. The data were compiled and entered in MS Excel sheet and subjected to statistical analysis.

Statistical analysis

The data on categorical variables are shown as n (%) and data on continuous variables are presented as mean and standard deviation across the study groups. The intergroup statistical comparison of distribution of categorical variables was done using the Chi-square test. The intergroup statistical comparison of means of continuous variables was done using an independent sample t-test. The intragroup statistical comparisons were done using paired t-test for each study group. The underlying normality assumption was tested before subjecting each variable to t-tests. All results were shown in tabular as well as graphical format to visualize the statistically significant difference more clearly.

In the entire study, P < 0.05 was considered to be statistically significant. All the hypotheses were formulated using two-tailed alternatives against each null hypothesis (hypothesis of no difference). The entire data were statistically analyzed using the Statistical Package for Social Sciences (SPSS version 21.0, IBM Corporation, Armonk, N.Y., USA ) for MS Windows.


  Results Top


Part I

Attitude toward treatment progress

The distribution of mean treatment progress scores such as perception of requirement of orthodontic treatment and opinion about adequacy of number of appointments planned did not differ significantly between the two study groups (P > 0.05 for all). The distribution of mean treatment progress scores such as perceived changes in smile, changes in face, changes in overall looks, and changes in overall personality was significantly higher in parents compared to patients with CLP (P < 0.05 for all). The distribution of mean treatment progress scores such as liking for wearing braces and satisfaction with treatment progress was significantly higher in patients with CLP as compared to the changes perceived by the parents (P < 0.05 for all) [Table 1].
Table 1: Attitude toward treatment progress

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Experience with the orthodontist [Table 2]

The distribution of responses related to experience with orthodontist such as experience with braces, experience with orthodontic treatment, experience with orthodontist, mean score of having answer for all questions, explanation of treatment procedure, and being criticized by an orthodontist for breakage did not differ significantly between the two study groups indicating a strong agreement (P > 0.05 for all).
Table 2: Experience with the orthodontist

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Part II

Experience with treatment duration [Table 3]
Table 3: Experience with treatment duration

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The distribution of responses related to treatment duration such as repeated appointments, intra-appointment interval, treatment time as per expectation, and stage of stopping treatment did not differ significantly between the two study groups (P > 0.05 for all).

Experience with oral hygiene and diet [Table 4]
Table 4: Experience with oral hygiene and diet

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The distribution of responses related to oral hygiene/diet such as difficulty in brushing with braces and extra time required for brushing was significantly higher in patients with CLP compared to the non-CLP group (P < 0.05 for all). The distribution of responses related to oral hygiene/diet such as requirement of mouthwash with braces and requirement of modification in dietary habits did not differ significantly between the two study groups (P > 0.05 for all).

Difficulties experienced [Table 5]
Table 5: Difficulties experienced

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The distribution of responses related to difficulties experienced such as pain experienced during treatment, ulcers in lips and cheeks, and mean score of embarrassment faced with braces did not differ significantly between the two study groups (P > 0.05 for all).


  Discussion Top


The overall dental health issues including esthetic problems are higher in patients with CLP as compared to non-CLP patients and may be attributed to tissue scarring due to previous surgeries, altered jaw growth, maligned teeth, and complex anatomy of the cleft defect. This may adversely affect the self-esteem and morale of these patients.[10],[11],[12] The long duration of treatment, involvement of multiple specialists, and multiple surgeries make these children and their parents more apprehensive toward the orthodontic care than their non-CLP counterparts. There is a shock feeling among parents of children with CLP at birth which gradually reduces with age and active participation of parents in the cleft care.[13],[14] It is also evident that it is the parents who usually take the final decision regarding the treatment of their children. Hence, assessment of attitude among parents of patients with CLP is equally important for a successful treatment outcome. Furthermore, a comparison of attitude of these patients as compared to their non-CLP counterparts is essential to provide information about requirement additional degree of care for these patients. Hence, Part I of this study was designed to study the agreement about orthodontic care between patients with CLP and their parents. Part II of the study compared the patients with CLP with their non-CLP counterparts.

Most studies in literature have shown a strong agreement in attitude between patients with CLP and their parents toward cleft treatment.[15],[16] Daniels et al.[17] in their study concluded that parents are more motivated than the children with CLP and they cooperated better during the orthodontic treatment. In our study, a strong agreement was observed in perceived requirement of orthodontic treatment between the patients and parents and they had similar opinions about adequacy of number of appointments planned by the orthodontists. The parents, however, had a better perception of changes in overall personality and facial and smile esthetics of their children. The experience with the orthodontist was also similar between the two groups indicating the adequacy of services provided by the orthodontists.

Orthodontic treatment in adolescent patients is usually motivated and adjudged by the peer influence[18] as in the age group selected in our study. The child may have a different opinion than their parents. The peer group in patients with CLP is usually the non-CLP population. Various studies have compared the clinician- and patient-based perception of treatment needs of their malocclusion. However, the authors could not find any study comparing the patients with CLP with non-CLP counterparts. Hence, a comparison has been made between the two groups pertaining to experience with treatment duration, oral hygiene/dietary problems and other difficulties faced during treatment so that any extra support/attention may be given to patients with CLP if required. In our study, on an average, both the groups were equally satisfied with their treatment duration and appointment planning by the orthodontist. This indicates no need of devising a separate appointment planning strategy for patients with CLP. Similarly, the requirement of mouthwash and dietary modification during treatment was similar for the two groups. However, the CLP group faced more difficulties in brushing with braces, and extra time was required for brushing which may be attributed to the complex orofacial anatomical problems in these patients.[19] Therefore, additional attention should be provided to patients with CLP during delivery of oral hygiene instructions and maintenance should be reviewed diligently in every appointment. The difficulties experienced by the patients with CLP such as pain experienced during treatment and development of oral ulcers were similar between the two groups indicating no requirement of a major change in orthodontic mechanotherapy for these patients. These findings are in concurrence with other studies in literature which suggest that no significant emotional and attitude difference exists in patients with CLP as compared to their non-CLP counterparts.[16],[20]


  Conclusions Top


From this study, it can be concluded that parental attitude and motivation form an important aspect in successful orthodontic treatment outcome in patients with CLP and they should be actively involved during all stages of treatment. A strong agreement between the child and parent's attitude toward treatment is important. Although the patients with CLP are emotionally comparable to their non-CLP counterparts, still special attention may be given to them during treatment secondary to low self-esteem due to impaired facial esthetics, difficulties in brushing, and oral hygiene maintenance owing to various anatomical complexities in these patients. A prospective study with a larger sample size is required to validate the findings of this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jenny J. A social perspective on need and demand for orthodontic treatment. Int Dent J 1975;25:248-56.  Back to cited text no. 1
    
2.
Albino JE, Cunat JJ, Fox RN, Lewis EA, Slakter ML, Tedesco LA. Variables discriminating individuals who seek orthodontic treatment. J Dent Res 1981;60:1661-7.  Back to cited text no. 2
    
3.
Lewis H, Brown W. The attitude of patients to the wearing of a removable orthodontic appliance. British Dent J 1973;134:87-90.  Back to cited text no. 3
    
4.
Albino JE. Factors influencing adolescent cooperation in orthodontic treatment. Semin Orthod 2000;6:214-23.  Back to cited text no. 4
    
5.
Sergl HG, Klages U, Zentner A. Functional and social discomfort during orthodontic treatment effects on compliance and prediction of patients' adaptation by personality variables. Eur J Orthod 2000;22:307-15.  Back to cited text no. 5
    
6.
Doll GM, Zentner A, Klages U, Sergl HG. Relationship between patient discomfort, appliance acceptance and compliance in orthodontic therapy. J Orofac Orthop 2000;61:398-413.  Back to cited text no. 6
    
7.
Noar JH. Questionnaire survey of attitude and concerns of patients with cleft lip and palate and their parents. Cleft Palate Craniofac J 1991;28;279-84.  Back to cited text no. 7
    
8.
Feldmanna I, Listb T, Johnc MT, Bondemarkd L. Reliability of a questionnaire assessing experiences of adolescents in orthodontic treatment. Angle Orthod 2007;77:311-17.  Back to cited text no. 8
    
9.
Santrock JW. Adolescence. 8th ed.. New York: McGraw-Hill; 2001.  Back to cited text no. 9
    
10.
Turner SR, Thomas PW, Dowell T, Rumsey N, Sandy JR. Psychological outcomes amongst cleft patients and their families. Br J Plast Surg 1997;50:1-9.  Back to cited text no. 10
    
11.
Pannbacker M, Lass NJ, Starr P. Information and experience with cleft palate: Students, parents, professionals. Cleft Palate J 1979;16:198-205.  Back to cited text no. 11
    
12.
Dabed C, Cauvi C. Survey of dentist's experience with cleft palate children in Chile. Cleft Palate Craniofac J 1998;35:430-3.  Back to cited text no. 12
    
13.
Semb G, Birchgrevink H, Saether IL, Ramstad T. Multidisciplinary management of cleft lip and palate in Oslo, Norway. In: Bardach J, Morris HL, editors. Multidisciplinary Management of Cleft Lip and Palate. Philadelphia: W B Saunders; 1990. p. 227-39.  Back to cited text no. 13
    
14.
Clifford E. Parental ratings of cleft palate infants. Cleft Palate J 1969;6:235-44.  Back to cited text no. 14
    
15.
Slutsky H. Maternal reaction and adjustment to birth and care of cleft palate child. Cleft Palate J 1969;6:425-9.  Back to cited text no. 15
    
16.
Wirls CJ, Plotkin RR. A comparison of children with cleft palate and their siblings on projective test personality factors. Cleft Palate J 1971;8:399-408.  Back to cited text no. 16
    
17.
Richman LC. Parents and teachers: Differing views of behavior of cleft palate children. Cleft Palate J 1978;15:360-4.  Back to cited text no. 17
    
18.
Daniels AS, Seacat JD, Inglehart MR. Orthodontic treatment motivation and co-operation: A cross sectional analysis of adolescent patients' and parents' responses. Am J Orthod Dentofac Orthop 2009;136:786-9.  Back to cited text no. 18
    
19.
Johnsen DC, Dixon M. Dental caries of primary incisors in children with cleft lip and palate. Cleft Palate J 1984;21:104-9.  Back to cited text no. 19
    
20.
Palmer JM, Adams MR. The oral image of children with cleft lip and palate. Cleft Palate Bull 1962;12:72-6.  Back to cited text no. 20
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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