orthodontic psychosocial impactsufdcimages.uflib.ufl.edu/uf/e0/00/07/28/00001/lawton_b.pdf ·...
TRANSCRIPT
ORTHODONTIC PSYCHOSOCIAL IMPACTS
By
BRETT THOMAS LAWTON
A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE
UNIVERSITY OF FLORIDA
2003
ii
ACKNOWLEDGMENTS
To my family, Mother and Father, and Lisa, I am grateful for their help and
support. My accomplishments would not have been possible without their love and
patience over the years.
To my wife, Laura, and daughter, Annabelle, I am very grateful for the patience
and support they have provided me throughout the many years of training. I look forward
to our lifetime of happiness.
To my committee—Drs. Wheeler, Dolan, Dolce, and McGorray—I appreciate their
dedication to me and insuring success throughout my training. I sincerely respect each of
them and their commitment to research and academic excellence.
iii
TABLE OF CONTENTS
Page ACKNOWLEDGMENTS ............................................................................................... ii ABSTRACT.................................................................................................................... iv INTRODUCTION ............................................................................................................1 MATERIALS AND METHODS......................................................................................4 RESULTS .........................................................................................................................8 DISCUSSION.................................................................................................................12 CONCLUSIONS.............................................................................................................16 APPENDIX. EXAMPLE OF SURVEY ADMINISTERED AT EACH DATA COLLECTION TIME POINT..................................................................................17 REFERENCES ...............................................................................................................19 BIOGRAPHICAL SKETCH ..........................................................................................21
iv
Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science
ORTHODONTIC PSYCHOSOCIAL IMPACTS By
Brett Thomas Lawton
May 2003
Chair: Timothy T. Wheeler Major Department: Orthodontics
The treatment impacts experienced by patients undergoing different orthodontic
treatment modalities are essentially unknown. With the advent of contemporary
techniques such as Invisalign, this information may prove to be influential for both the
patient and practitioner. As a component of an ongoing prospective clinical trial we
assessed the psychosocial impacts of orthodontic treatment on 37 patients with traditional
edgewise appliances in comparison to one hundred patients undergoing treatment with
Invisalign. Impacts were assessed using a modified General Oral Health Assessment
Index (GOHAI). Participants completed surveys at pretreatment baseline, 3, 6, 12, and 18
months and at the completion of treatment. The treatment groups were comparable in
terms of age, sex, race, marital status, and previous orthodontic treatment. However, the
Invisalign group showed higher levels of education and income (p=0.02), which may
influence the reports of treatment impact. There were limited differences in the
experience patients undergo regardless of which treatment method is used. One exception
was that Invisalign patients reported more impacts at 6 months in comparison to
v
edgewise patients (p=0.02). However, this difference was not appreciable at any other
time. Overall, the two treatment groups reported similar treatment impacts, with few
differences by treatment method.
1
INTRODUCTION
The psychosocial impacts of orthodontic treatment on patients have not been well
studied. Better understanding of treatment impacts including pain, discomfort, difficulty
chewing, eating or swallowing or interference with daily activities could facilitate patient
expectations during treatment. Moreover, as new techniques are introduced to the
orthodontic armamentarium, it is crucial that both parties are aware of key differences that
exist specific to the proposed means of treatment.
Medical and dental practitioners are experiencing a radical transformation from the
traditional, intuitive, unsystematic and paternalistic ideology of providing care to one
respecting evidence-based, patient-centered outcomes (Fernandes et al., 1999). A
dichotomy of information now exists between (1) the clinician formulating a rational,
objective means for treatment, and (2) the consumer perspective and subjective information
one regards as integral to a successful outcome (Vig et al., 1999). Whereas the foundation
for bridging communication between patient and provider has been established, a
significant divide still exists which hinders each party’s ability to express more subjective
emotions including satisfaction and expectations.
The satisfaction a patient feels towards treatment is often difficult to define and
assess. In the simplest of terms, satisfaction may be understood as fulfillment one receives
resulting from an event or service (Miller, 1977). A more contemporary definition states
that treatment satisfaction amounts to the difference between what the patient expects and
what the patient receives (Vig et al., 1999; Day, 1977). A more philosophical
2
understanding of treatment satisfaction involves the individual’s perceived value of
services provided and the resultant behavior they express as a result (Linder-Pelz , 1982;
Vig et al., 1999).
Contemporary medicine and dentistry have been subject to an emerging trend of
analyzing patient satisfaction. It is clear that this term satisfaction is rather broad in scope,
composed of many unique aspects that combine to portray a sense of satisfaction with
treatment. Such factors include well studied ideas including happiness with providers,
opinion of treatment results, and convenience of care provided. However, psychosocial
impacts including pain, discomfort, difficulty in chewing and interference of social
interaction have not been analyzed. Patients undergoing orthodontic treatment may
experience significant psychosocial impacts including the inability to speak clearly, eat
efficiently, sleep or relax, smile without embarrassment, or maintain their normal
emotional, social or business roles and responsibilities.
There is little literature concerning patient experience and attitude towards
orthodontic therapy (Lew, 1993). Current quality of life measures developed for dentistry
are commonly inapplicable to assess such interactions in orthodontics (O’Brien et al.,
1998) given the lack of a diseased state of oral health and the elective nature of cosmetic
treatment. Furthermore, extended duration of orthodontic treatment and cyclic,
intermittent discomfort associated with activation of appliances establish the experience
patients undergo to be unique. The orthodontic patient population, their motivation and
their expectations for a pleasing outcome are key factors that must be considered to
accurately report patient satisfaction with the orthodontic experience. It then becomes
3
necessary to further our understanding of the subjective perceptions patients experience
while undergoing orthodontic treatment.
The Department of Orthodontics at the University of Florida was commissioned
to execute a prospective clinical trial of 100 Invisalign patients to analyze a number of
factors. We felt the psychosocial impacts associated with various orthodontic treatment
modalities were in need of further study. Thus, the opportunity to compare these impacts
between subjects undergoing edgewise or Invisalign treatment was available and
convenient for study. This pilot study was designed to capture the self-reported impacts
both populations experience in hopes that we may more clearly understand how
influential differing modalities of treatment affect orthodontic patients.
4
MATERIALS AND METHODS
A prospective, longitudinal study was conducted to compare the influences that
orthodontic treatment had on patients with traditional edgewise appliances in comparison to
others undergoing treatment with Invisalign in a current clinical trial. All subjects were
treated in the resident, faculty or research orthodontic clinics at the University of Florida,
College of Dentistry in Gainesville, Florida. Subjects were at least 18 years of age, willing
to sign informed consent, in good health, and able to be treated without extractions
excluding a single lower incisor or third molars. The institutional review board for research
at the University of Florida approved the protocol prior to beginning the study.
One hundred Invisalign and thirty-seven edgewise patients were recruited to
participate in the study. Five Invisalign and three edgewise patients dropped out of the
study for a final sample of 95 and 34 patients, respectively. Unique identification
numbers were assigned to each patient. The sample consisted of 85 females and 44 males,
and a mean age of 29.1 years ranging from18 to 58 years.
The surveys administered [see appendix] were a compilation of previously
described methods used in the general oral health assessment index (GOHAI), the Rand
Health Insurance study (RHIS) and contemporary work by Locker (1997). The GOHA
index is regarded as a valid means in relating psychosocial effects of one’s oral health
condition without the presence of a disease state (Atchison, 1997; Atchison and Dolan,
1990). This index was designed to evaluate three aspects of oral health status: 1) physical
function (i.e. eating, speech, and swallowing); 2) psychosocial function (anxiety, concern
5
about oral health, withdraw from social interactions secondary to oral health status); and
3) pain or discomfort of the oral cavity. The RHIS study aimed to quantify the amount of
pain, worry and concern with social interactions secondary to diseased oral health status.
Locker modified these methods by recording nominal and ordinal responses pertaining to
subjects’ ability to function in specific cases such as chewing firm meat, or eating an
apple. The compilation of these three indices resulted in the four questions that were
asked as a part of the survey. The fifth question was open ended and allowed for any
additional input the patient desired to share with the researcher in regards to their oral
health status.
Participants completed identical surveys at baseline/pre-treatment, 3-, 6-, 12- and
18 months and at the end of treatment [see appendix]. Surveys were administered at the
beginning of each visit corresponding to the data collection time point. Subjects
completed the survey based on their experience since their last orthodontic visit.
Demographic data was also collected from both samples [Table 1].
All responses were recorded in an ordinal manner with one open-ended question
for patients to make additional notes if necessary. The ordinal responses from each of the
four questions were summed and compared. The mean and median values for each
population were then compared. Figures 2-5 graphically represent the recorded responses
for each question over the aforementioned time points. The demographic and survey data
were evaluated by means of Wilcoxon Rank Sum and two-sample t-tests. Spearman
correlation coefficients were used to evaluate similarities between the two populations.
6
Table 1: Summary of Demographic Data Invisalign Edgewise Age Mean Age in years 30.6 27.5 Standard Deviation 9.54 9.09 Minimum 18.1 18.8 Maximum 56.4 58.4 Education Level <HS Graduate 0% 6% HS Graduate 10% 16% Some College 31% 28% College Graduate 59% 50% Income under $10,000 11% 20% 10,000-25,000 16% 36% 25,000-50,000 26% 19% 50,000-75,000 24% 6% 75,000-100,000 7% 6% 100,000+ 16% 13% Marital Status (%) married 46% 34% divorced 6% 9% never married 47% 56% Previous Ortho Treatment No 78% 69% Yes 22% 31% Race Information Black 7% 10% Hispanic 7% 6% Other 6% 9% White 80% 75% Sex Female (n=85) 68% 59% Male (n=44) 32% 41% Students No 57% 38% Yes 43% 62%
7
RESULTS
A significant number of baseline differences were detected between the two
populations in question [Figures 1-4]. Questions 1, 3 and 4 indicate the Inivisalign
sample began treatment with less dental impacts than the edgewise group, although
significant changes were appreciable throughout the course of treatment. Because of the
baseline differences, we adjusted the data to reflect the changes from each group’s
baseline to more accurately reflect the impact change over time. When comparing each
population’s change from baseline, it appears the Invisalign population is more
negatively impacted at 6 months than the edgewise sample (p=0 .0253). However, this
relationship appeared transient and was not demonstrated at the following data collection
time point of one year.
Positive correlations in both samples indicate consistent relationships in the
survey responses [Table 2], although no significant correlation existed within the
edgewise group between survey [see appendix] questions 2 and 4 (r2 = 0.08, p=0.12) and
questions 3 and 4 (r2 = 0.08, p=0.10). Given these correlations, the applied survey appears
to elicit similar relationships each sample group recorded.
Demographic information [Table 1] showed similarities in both sample
groups. The study population consisted of approximately twice as many women (n=85)
as compared to men (n=44), at least 50% with college degrees, and approximately 2/3
receiving previous orthodontic treatment. The Invisalign population reported a
significantly higher annual income (p=0.0234) [Figure 5] and had more education,
8
although this finding was not statistically significant (p=0.07). The edgewise group was
composed of more current students than Invisalign (p=0.052). No significant differences
were appreciable between groups in marital status, age, sex, race or history of previous
orthodontic treatment.
Question 1
46
47
48
49
50
51
52
53
54
Baseline 3 months 6 months 12 months
Timepoint
Mea
n R
ecor
ded
Valu
e
Invisalign
Edgew ise
Figure 1: Mean recorded values from survey question 1 for time points baseline through 12 months. Significant baseline differences appreciable between groups. Invisalign started off higher (better), and tends to report more positive findings over time. Edgewise group is significantly lower at baseline and 3 months, equal at 6 months, and slightly lower at 12 months. Slight upward trend appreciable for both samples.
9
Question 2
20
21
22
23
24
25
26
Baseline 3 months 6 months 12 monthsTimepoint
Mea
n R
ecor
ded
Valu
e
Invisalign
Edgew ise
Figure 2: Mean recorded values from survey question 2 for time points baseline through 12. months. No significant differences appreciable in the societal and professional impacts between treatment groups.
Question 3
24
25
26
27
28
29
30
Baseline 3 months 6 months 12 monthsTimepoint
Mea
n R
ecor
ded
Valu
e
Invisalign
Edgewise
Figure 3: Mean recorded values from survey question 3 for time points baseline through 12 months. Higher recorded value indicates less impact on eating and speaking. Similar differences reported over time. Invisalign tends to report more positive findings over time.
10
Question 4
0
0.5
11.5
2
2.5
33.5
4
4.5
Baseline 3 months 6 months 12 monthsTimepoint
Mea
n Re
cord
ed V
alue
Invisalign
Edgewise
Figure 4: Higher recorded value indicates less pain. Significant baseline differences indicate Invisalign sample had less baseline dental discomfort. Demonstrates minimal negative impact upon reported pain levels overall.
11
Income Differences
010203040
<10K
10-25
K
25-50
K
50-75
K
75-10
0K>1
00K
Annual Income
Perc
enta
ge
Invisalign
Edgew ise
Figure 5: Reported annual income of the study group.
Table 2: Spearman correlation coefficients for each population. Positive correlation indicates similarity in responses within and between groups. All correlations were significant except for questions 2 and 4 and questions 3 and 4 for the edgewise group.
Invisalign Correlations Question 2 Question 3 Question 4 Question 1 r=0.27
p=0.009* r=0.51 p<0.001*
r=0.23 p=0.0246*
Question 2
r=0.25 p=0.0131*
r=0.35 p=0.0005*
Question 3
r=0.36 p=0.0003*
Edgewise Correlations
Question 2 Question 3 Question 4 Question 1 r=0.37
p=0.046* r=0.48 p=0.0068*
r=0.6 p=0.0004*
Question 2
r=0.5 p=0.004*
r=0.29 p=0.12
Question 3
r=0.29 p=0.10
12
DISCUSSION
The results of this study regarding the psychosocial impacts of orthodontic care
are inconclusive. Few significant differences between sample groups are appreciable.
Moreover, there were significant baseline differences that make comparison of each
group difficult and perhaps misleading. To adjust for baseline differences, we compared
the difference each sample group experienced since baseline. The one significant
difference observed between the edgewise and Invisalign group at 6 months was
transient and not appreciable at the following data collection time point of 12 months.
No clear explanation is available to justify this finding. One may speculate the
edgewise patients may have experienced the majority of discomfort early on, and now
appreciate the results as their chief complaint has been resolved. It is possible that the
Invisalign sample may be dissatisfied in the progress at this time, especially if the
aligners are not fitting correctly, if they require extensive interproximal reduction, or
perhaps requiring their case to be rebooted due to inconsistencies. Why this concern is
not appreciable at one year is unfounded.
When analyzing the results for each question, several interesting points are
noteworthy. Question 1 elicited a more positive response from Invisalign patients over
time, although both sample groups demonstrate a slight upward trend. Question 2
demonstrated very little difference in the societal and functional impacts each sample
experienced. This finding suggests that orthodontic treatment regardless of modality has
little, if any, impact on patients’ professional roles and social responsibilities. Question 3
13
addresses similar concerns to question 1 in regards to the impact on patients’ ability to eat
or speak effectively. Invisalign patients reported significantly more positive findings over
time indicating less impact from treatment. Question 4 addressed the level of pain or
discomfort for each population. A significant baseline difference was noted as edgewise
patients elicited responses suggestive of more dental pain in comparison to the Invisalign
sample. This difference in reported discomfort was not significant at other time points.
The study population was unique for several reasons in comparison to the typical
adolescent population that dominates most orthodontic practices. Approximately three
times as many adult women elect to receive treatment compared to men (Nattras et al.,
1995), and whom at least half have received a college education (Sergl and Zentner,
1997; Kiyak et al., 1985). Approximately 20% (McKiernan et al., 1992) to 50% (Sergl
and Zentner, 1997) have undergone previous orthodontic treatment.
The increase in the number of adults seeking orthodontic treatment has been
attributed to a number of possible factors, including increased public awareness,
increased preoccupation with health and appearance, the increased availability of
resources, and expanded demand for orthodontic support to other dental specialties
(McKiernan et al., 1992). In addition, Breece and Nieberg have reported a general
increase in social acceptability of appliance therapy (Breece and Nieberg, 1986).
Technologic advances have played a significant role in this phenomenon with the advent
of long-duration memory wires, low profile or ceramic brackets (Kuhlberg et al., 1997),
and contemporary treatment modalities, such as Invisalign. (Nattrass et al., 1995)
The data in this study suggest limited differences in treatment impacts exist
between the Invisalign or edgewise populations. Literature in support of this finding
14
suggests adults may be less influenced by their peer perceptions, and are more stable in
their concerns about appearance compared to adolescents (Stenvik et al., 1996). Indeed,
many authors recognize the desire for improvement as a sign of ego strength not
weakness (Kiyak et al., 1984; Proffit, 1993). The preliminary data from this pilot study
may suggest adults do not appreciate a significant difference in how Invisalign or
edgewise appliances influence their lives, but moreover how orthodontic treatment in
general affects them.
Several potential weaknesses to this study are worthy of mention. Feine and
colleagues (Feine et al., 1998) reported patients cannot accurately recall differing
intensities of pain over time, and the perceived discomfort greatly depends on the level of
pain before treatment. The literature suggests the discomfort these subjects reported is not
accurate given the retrospective nature in which they were polled, and the extended
duration of time between data collection time points ranging from one to 6 months.
Furthermore, subjects were polled to record the treatment impacts since their last visit,
which may be highly variable and deceiving for each patient. It is likely that key
differences exist between the two samples immediately following the initiation of
treatment or shortly after a change in wires or aligners. As a result of these unknown
variables, a study to record these differences by means of a similar survey administered
daily for one week immediately following the first day of active treatment has been
started.
Several weaknesses existed in the sample populations for this study. The
Invisalign population was concurrently involved in an ongoing university study
analyzing a multitude of factors in addition to this survey. Variations in treatment
15
requirements, mechanics and protocols associated with such a clinical trial may
compound the variability in this data, and may not be reflective of the experience in
private practice. The sample size difference is significant between the two populations
studied. The edgewise population was limited primarily due to the lack of adult patients
meeting the inclusion criteria in the university setting. Lastly, the significant differences
at baseline limit the ability to draw firm conclusions regarding the difference in impacts
experienced by each sample group. Further study of patient satisfaction in the private
sector has been initiated to evaluate these potential differences.
16
CONCLUSIONS
Although this study did not demonstrate any appreciable differences in treatment
impacts between edgewise and Invisalign patients, further study is indicated.
Orthodontists should be concerned for the satisfaction of patients and the impacts of
treatment. Likewise, the success of patient treatment and the specialty of orthodontics
demand a better understanding of the emotional and functional transformations incurred
in orthodontics. Such information will certainly be of great benefit to both the patient and
the practitioner.
17
APPENDIX EXAMPLE OF SURVEY ADMINISTERED AT EACH
DATA COLLECTION TIME POINT 1. Please circle one response for each of the following questions.
In the past month, how often: Always Often Some-
times Seldom Never
a. did you limit the kinds or amounts of food you eat because of problems with your mouth or teeth?
1
2
3
4
5
b. did you have trouble biting or chewing any kinds of food, such as firm meat or apples?
1
2
3
4
5
c. were you able to swallow comfortably? 1 2 3 4 5 d. did your teeth prevent you from speaking the way
you wanted?
1
2
3
4
5 e. were you able to eat anything without feeling
discomfort?
1
2
3
4
5 f. did you limit contact with people because of the
condition of your mouth or teeth?
1
2
3
4
5 g. were you pleased or happy with the looks of your
mouth or teeth?
1
2
3
4
5 h. did you use medication to relieve pain or discomfort
from around your mouth?
1
2
3
4
5 i. were you worried or concerned about the problems
with your mouth or teeth?
1
2
3
4
5 j. did you feel nervous or self-conscious because of
problems with your mouth or teeth?
1
2
3
4
5 k. did you feel uncomfortable eating in front of people
because of problems with your mouth or teeth?
1
2
3
4
5 l. were your teeth sensitive to hot, cold, or sweets?
1
2
3
4
5 2. During the past month, how often has pain, discomfort, or other problems with your mouth or teeth caused you
to… (Please circle one response)
All of the time
Very Often
Fairly Often
Some-times
Never
a. Have difficulty sleeping? 1 2 3 4 5
b. Stay home more than usual? 1 2 3 4 5
c. Take time off work or school? 1 2 3 4 5
d. Be unable to do household chores? 1 2 3 4 5
e. Avoid your usual leisure activities? 1 2 3 4 5
18
3. Thinking about your dental health over the past month, how often…
All of the time
Very Often
Fairly Often
Some-times
Never
a. Have you been prevented from eating foods you would like to eat?
1 2 3 4 5
b. Have you found your enjoyment of food is less than it used to be?
1 2 3 4 5
c. Did it take you longer to finish a meal than other people?
1 2 3 4 5
d. Did you have difficulty pronouncing any words? 1 2 3 4 5
e. Did you have difficulty speaking clearly? 1 2 3 4 5
f. Did you have difficulty making yourself understood? 1 2 3 4 5
4. During the past month, how much pain or discomfort have your teeth or mouth caused you? (please circle one response)
1 a great deal of pain 2 some pain 3 a little pain 4 no pain at all
5. Are you having any other problems or concerns about your teeth or mouth? If so, please describe.
________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________
19
REFERENCES
Atchison KA. General Oral Health Assessment Index. In: Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill: University of North Carolina, Dental Ecology 1997.
Atchison KA, Dolan TA. Development of the Geriatric Oral Health Assessment Index. J
Dent Educ 1990; 54: 680-87. Bergstrom K, Halling A, Wilde B. Orthodontic care from the patients’ perspective:
perceptions of 27-year-olds. Eur J Orthod. 1998 Jun; 20(3):319-29. Breece GL, Nieberg LG. Motivations for adult orthodontic treatment. J Clin Orthod. 1986
Mar; 20(3):166-71. Day RL. Toward a process model of consumer satisfaction. In: Hunt HK (ed.)
Conceptualization of Consumer Satisfaction and Dissatisfaction. Cambridge: Marketing Science Institute, 1977
Dolan TA, Gooch BR. Dental Health questions form the Rand Health Insurance Study.
In: Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill: University of North Carolina, Dental Ecology 1997.
Feine JS, Lavigne GJ, Dao TT, Morin C, Lund JP. Memories of chronic pain and
perceptions of relief. Pain. 1998 Aug;77 (2):137-41. Fernandes LM, Espeland L, Stenvik A. The provision and outcome of orthodontic
services in a Norwegian community: a longitudinal cohort study. Community Dent Oral Epidemiol. 1999 Jun; 27(3):228-34.
Kiyak HA, McNeill RW, West RA. The emotional impact of orthognathic surgery and
conventional orthodontics. Am J Orthod. 1985 Sep;88 (3):224-34. Kuhlberg AJ, Glynn E. Treatment planning considerations for adult patients. Dent Clin
North Am. 1997 Jan; 41(1):17-27. Lew KK.Attitudes and perceptions of adults towards orthodontic treatment in an Asian
community.Community Dent Oral Epidemiol. 1993 Feb; 21(1):31-5. Linder-Pelz S. Toward a theory of patient satisfaction. Soc Sci Med 1982; 16:577-582
20
Locker D. Subjective oral health status indicators. In: Slade GD, ed. Measuring Oral Health and Quality of Life. Chapel Hill: University of North Carolina, Dental Ecology 1997.
McKiernan EX, McKiernan F, Jones ML. Psychological profiles and motives of adults
seeking orthodontic treatment. Int J Adult Orthodon Orthognath Surg. 1992; 7(3):187-98.
Miller JA. Studying satisfaction, modifying models eliciting expectations, posing
problems, and making meaningful measurements. In: Hunt HK (ed.) Conceptualization of Consumer Satisfaction and Dissatisfaction. Cambridge: Marketing Science Institute, 1977
Nattrass C, Sandy JR. Adult orthodontics--a review. Br J Orthod. 1995 Nov; 22(4):331-7. Nurminen L, Pietila T, Vinkka-Puhakka H. Motivation for and satisfaction with
orthodontic-surgical treatment: a retrospective study of 28 patients. Eur J Orthod. 1999 Feb; 21(1):79-87.
O'Brien K, Kay L, Fox D, Mandall N. Assessing oral health outcomes for orthodontics--
measuring health status and quality of life. Community Dent Health. 1998 Mar;15(1):22-6.
Proffit WR Special considerations in comprehensive treatment of adults. In:
Contemporary Orthodontics. 2nd ed. St. Louis: Mosby-Year Book; 1993: 585-606. Proffit WR, Fields HW, Moray LJ. Relevance of malocclusion and orthodontic treatment
need in the United States: estimates from the NHANES III survey. Int J Adult Orthodon Orthognath Surg. 1998; 13(2):97-106.
Sergl HG, Zentner A. Study of psychosocial aspects of adult orthodontic treatment. Int J
Adult Orthodon Orthognath Surg. 1997; 12(1):17-22. Sinha PK, Nanda RS, McNeil DW. Perceived orthodontist behaviors that predict patient
satisfaction, orthodontist-patient relationship, and patient adherence in orthodontic treatment. Am J Orthod Dentofacial Orthop. 1996 Oct; 110(4):370-7.
Stenvik A, Espeland L, Berset GP, Eriksen HM. Attitudes to malocclusion among 18-
and 35-year-old Norwegians. Community Dent Oral Epidemiol. 1996 Dec; 24(6):390-3.
Vig KW, Weyant R, O'Brien K, Bennett E. Developing outcome measures in
orthodontics that reflect patient and provider values. Semin Orthod. 1999 Jun; 5(2):85-95.
21
BIOGRAPHICAL SKETCH
Brett Thomas Lawton was born in Winter Park, Florida. He received his Bachelor
of Arts degree in neuroscience and a minor in Spanish from Vanderbilt University in
Nashville, Tennessee, in 1996. He received his Doctor of Dental Medicine degree from
the University of Kentucky in Lexington, Kentucky, in 2000. Dr. Lawton continued his
dental education at the University of Florida to receive his Master of Science degree with
a certificate in orthodontics. At the University of Florida Dr. Lawton was involved in
clinical research analyzing the psychosocial impacts patients experience while
undergoing orthodontic treatment.