ORIGINAL ARTICLE

Factors affecting patients' adherence

to orthodontic appointments
Omair M. Bukhari,a Keyvan Sohrabi,b and Mary Tavaresc
Boston and Cambridge, Mass, Mecca, Saudi Arabia, and Seattle, Wash

Introduction: Studies show that attendance at orthodontic appointments affects treatment outcomes, treatment
duration, and the probability of side effects. The aim of this study was to predict factors that influence patients'
attendance at orthodontic appointments. Methods: We conducted a face-to-face guided interview survey of 153
participants from orthodontic clinics in the Greater Boston area. Attendance at scheduled orthodontic
appointments was self-reported as always, sometimes, or rarely. Participants' characteristics, including
demographics, dental insurance, and oral hygiene practices, were self-reported. Moreover, from dental
records, we collected the time that the participants spent undergoing active orthodontic treatment.
Multivariable ordered logistic regression was used to report proportional odds ratios and attendance
probabilities. A likelihood ratio test was performed to ensure that the proportional odds assumption held.
Results: For overall appointment attendance, 76% of the participants reported always attending, 16% reported
sometimes attending, and 8% reported rarely attending. Based on multivariable logistic regression (adjusted for
age, race, and sex), the participants with optimal oral hygiene practices were almost 6 times (5.9) more likely to
attend appointments than those who did not (P 5 0.002). The odds of attending appointments decreased signif-
icantly (by 23%) for every 6-month increase in treatment duration (P 5 0.008). Participants covered by non-
Medicaid insurance were 4 times (P 5 0.018) more likely to attend appointments than were those with
Medicaid insurance. Conclusion: Our findings indicate that adherence to orthodontic treatment follow-up
visits was strongly correlated to insurance type, treatment duration, and oral hygiene practices. Unlike
previous studies, sex was not a significant predictor of adherence. (Am J Orthod Dentofacial Orthop
2016;149:319-24)

A
challenging task facing a dental team is sup- adherence means attending appointments, maintaining
porting patients in changing their oral health good oral hygiene, wearing elastics or functional appli-
behaviors and maintaining those changes.1 Ac- ances as instructed, and avoiding foods that can loosen
cording to the American Association of Orthodontists, the brackets.
because orthodontic treatment is seldom finished In 2003, Trenouth3 found that the failure rate of pa-
rapidly, the assumption would be that patients who tients who completed orthodontic treatment was 10.3%,
want good-looking smiles and healthier occlusions and the failure rate of patients who discontinued ortho-
would attend every appointment and comply with every dontic treatment was 21.4%. Therefore, we could say
treatment instruction to accomplish the desired that attendance affected treatment success. In other
outcome as rapidly as possible.2 In orthodontics, studies, “no-show” rates for orthodontic appointments
a
ranged from 13.6%4 to 23.3%.5 Patients who neglected
Resident, Harvard School of Dental Medicine, Boston, Mass; lecturer, Faculty of
Dentistry, Umm Al-Qura University, Mecca, Saudi Arabia. orthodontic appointments during active treatment were
b
Resident, School of Dentistry, University of Washington, Seattle, Wash. likely to prolong their treatment durations6-9; as a result,
they might experience more harmful side effects.10
c
Senior clinical investigator, Forsyth Institute, Cambridge, Mass; program direc-
tor, Dental Public Health Residency, Oral Health Policy and Epidemiology, Har-
vard School of Dental Medicine, Boston, Mass. Missed appointments decrease the possibility that ortho-
All authors have completed and submitted the ICMJE Form for Disclosure of Po- dontic treatment will be completed successfully.3
tential Conflicts of Interest, and none were reported. The American Association of Orthodontists Insurance
Address correspondence to: Omair M. Bukhari, Harvard School of Dental Medi-
cine, Oral Health Policy and Epidemiology, REB 204, 188 Longwood Ave, Boston, Company suggests the following possible causes for a
MA 02115; e-mail, [email protected]. patient's failure to keep orthodontic appointments:
Submitted, April 2015; revised and accepted, July 2015. teenaged patients who are less than passionate about
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists. treatment; an unexpected illness or a crisis in the family;
http://dx.doi.org/10.1016/j.ajodo.2015.07.040 and adults who report interferences with work schedules
319
320 Bukhari, Sohrabi, and Tavares

Table I. Characteristics of respondents from the 3 orthodontic practices stratified by responses to attendance
question
Characteristic/answer to the question Always (n 5 116) Sometimes (n 5 25) Rarely (n 5 12) Total (n 5 153) P value (X2)
Age category (y) 0.309
\12 21 (81%) 5 (19%) 0 26 (100%)
12 to \16 58 (77%) 9 (12%) 8 (11%) 75 (100%)
.16 37 (71%) 11 (21%) 4 (8%) 52 (100%)
Sex 0.038
Male 48 (67%) 17 (24%) 7 (9%) 72 (100%)
Female 68 (84%) 8 (10%) 5 (6%) 81 (100%)
Race 0.075
White 37 (84%) 2 (5%) 5 (11%) 44 (100%)
Black 37 (69%) 15 (28%) 2 (3%) 54 (100%)
Hispanic 31 (76%) 6 (15%) 4 (9%) 41 (100%)
Other 11 (79%) 2 (14%) 1 (7%) 14 (100%)
Insurance type 0.022
Medicaid 64 (69%) 18 (19%) 11 (12%) 93 (100%)
Non-Medicaid 52 (87%) 7 (12%) 1 (1%) 60 (100%)
Brushing/flossing daily 0.003
Yes 101 (81%) 15 (12%) 8 (7%) 124 (100%)
No 15 (52%) 10 (34%) 4 (14%) 29 (100%)
Mean time of active treatment (SD)* (mo) 8.8 (6.7) 7.3 (5.8) 10.8 (7.2) 21 (16) 0.322*
Mean age (SD)* (y) 14.6 (4) 14.8 (2.6) 15.4 (3.5) 14.7 (3.9) 0.740*

*Based on ANOVA test.

and emotional pressures.2 An additional cause, probably were recruited from 3 private orthodontic offices in Bos-
the most critical and frequent cause, is that the patient ton, Cambridge, and Somerville. One hundred fifty-three
simply forgot.11,12 Forgetting indicates patient participants were invited to participate in the study, and
behavioral attitudes and oral health literacy. none refused or was unable to complete the question-
Although previous behavioral epidemiologic studies naire because of literacy problems. The subjects included
have tried to establish a connection between a patient's 81 girls (53%) and 72 boys (47%). Their mean age was
compliance with treatment, missed appointments, and 14.7 years (SD, 3.9 years), and the mean average treat-
oral hygiene, we could not find a study performed in ment time was 21 months (SD, 16 months). Demo-
private orthodontic offices in the United States. graphics and participants' characteristics are shown in
Although it is commonly thought that there is a corre- Table I. Overall, there were 54 African Americans
lation among elastic wear, showing up for appoint- (34.6%), 44 whites (28.8%), 41 Hispanics (27.6%), and
ments, and oral hygiene level, studies have shown 14 (9%) participants from other ethnic backgrounds.
contradictory results. Moreover, because of a lack of Medicaid insurance was used by 93 of the participants
consensus about factors affecting attendance and the (60.9%). Patients with severe dentofacial deformities
high percentage of malpractice claims against ortho- were excluded. Parents' consents and children's assents
dontists who have frequent no-show patients, the were obtained.
American Association of Orthodontists Insurance Com- This was a convenience sample of patients who
pany recommends paying close attention to patient agreed to take the surveys and signed the consent
attendance deficiencies and addressing them as early form. The study was approved by Committee on Human
as possible. Therefore, in this study, we predicted that Studies of Harvard University Faculty of Medicine.
attendance through a set of variables collected during The participants completed self-administered ques-
the first visit would help to predict possible future tionnaires guided by a face-to-face interview. The ques-
attendance behavior, improve outcomes, and reduce tionnaire was divided into 8 parts: (1) demographic data,
the percentage of malpractice claims associated with (2) oral hygiene practices, (3) payment method, (4)
no-show patients. attendance history, (5) patients' and parents' percep-
tions about the importance of braces, (6) treatment
duration (actual time that the participant was undergo-
MATERIAL AND METHODS ing active orthodontic treatment), (7) Oral Impact on
The study population was orthodontic patients in the Daily Performances scores, and (8) Peer Assessment Rat-
Greater Boston area of Massachusetts. The participants ing scores.

March 2016
Vol 149
Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Bukhari, Sohrabi, and Tavares 321

Before the actual data collection, the questionnaire

Table II. Results from multivariable logistic regres-
sets were validated in a pilot study, conducted in waiting
sions with attendance as a dependent variable
rooms of the Harvard dental clinic. This article will report
adjusted for sex and race
and predict patients' attendance history.
Patient attendance history was addressed by the Model 2: ordered
question “Have you visited the orthodontist after having Model 1: logistic logistic regression
regression treating treating age
an appointment?” with possible responses of always, Predictor age categorically continuously
sometimes, and rarely. Age category (y)
The data collection procedure had 2 main stages. \12 (reference)
First, the participants completed questionnaires that 12 to \16
included questions about the parents' perceived Odds ratio 0.7 1
95% CI 0.12-4.20 0.85-1.20
need for orthodontic treatment, behavioral attitude, P value 0.703 0.951
and sociodemographic information. An interviewer .16
was available to clarify any questions. Second, the Odds ratio 1
Oral Impact on Daily Performance and Peer Assess- 95% CI 0.15-6.79
ment Rating scores were calculated from the Oral P value 0.995
Insurance type
Impact on Daily Performance questionnaire and the Medicaid (reference)
study casts, respectively. Non-Medicaid
Odds ratio 3.6* 4.0*
95% CI 1.13-11.61 1.26-12.47
Statistical analysis P value 0.029 0.018
Brush/floss daily
A descriptive analysis was performed for the demo- No (reference)
graphic data to summarize the overall distribution of Yes
the characteristic variables, and bivariate analyses Odds ratio 6.9y 5.9y
(chi-square and analysis of variance [ANOVA]) were per- 95% CI 2.2-23.29 1.93-17.85
formed to assess the associations between independent P value 0.002 0.002
Treatment duration (mo)
variables and attendance history. Odds ratio 0.8* 0.77*
The first model used the multivariable ordered logis- 95% CI 0.66-0.97 0.64-0.94
tic regression to predict attendance history and examine P value 0.023 0.008
the simultaneous association of independent and *P \0.05; yP \0.01.
outcome variables. The associations between the inde-
pendent and outcome variables were adjusted for age
(continuous), sex, and race. To determine which addi- All analyses were conducted using a statistical
tional variables needed to be adjusted, we used the pur- package (version 12.0; Stata, College Station, Tex). All
poseful selection method.13 The estimated attendance statistical tests were 2-sided, and a P value of \0.05
probabilities and odds ratios were reported. Finally, a was deemed to be statistically significant.
likelihood ratio test was performed to ensure that the
proportional odds assumption held. RESULTS
The second model used the multivariable logistic Among the girls, the proportions who reported
regression with the binary outcome attendance history they always, sometimes, and rarely attended were
(always vs sometimes or rarely) while adjusting for age 84%, 10%, and 6%, respectively. On the other hand,
(\12, 12 to \16, .16 years) to determine whether the boys reported always, sometimes, and rarely
teenaged participants driving themselves attended their attending at 67%, 24%, and 9%, respectively. Overall,
orthodontic appointments differently from other the girls were more likely to attend than the boys
participants. (P 5 0.038; chi-square test).
We tested whether there were any significant differ- Among the Medicaid participants, the proportions
ences in patient characteristics between the 3 orthodon- who reported they always, sometimes, and rarely at-
tic offices. Moreover, we added the variable of the 3 tended were 69%, 19%, and 12%, respectively. Among
offices to our models. However, it was not significant the non-Medicaid participants, the proportions who re-
and did not change the coefficients of other predictors. ported they always, sometimes, and rarely attended were
Consequently, to have a simpler model, easier interpre- 87%, 12%, and 1%, respectively. Overall, non-Medicaid
tations, and better understanding by readers, we participants were more likely to attend than Medicaid
removed it from all models. participants (P 5 0.022; chi-square test).

American Journal of Orthodontics and Dentofacial Orthopedics March 2016
Vol 149
Issue 3
322 Bukhari, Sohrabi, and Tavares

Probabilities of different attendance categories

1
probability of A
probability of S
.8 probability of R
Probability

.6

.4

.2

0
0 20 40 60 80
Treatent Duration in Months
A: Always attend
S: Sometimes attend
R: Rarely attend

Fig. Probabilities of attendance over treatment duration.

Among participants with good oral hygiene practices, For every 6-month increase in treatment duration,
the proportions who reported they always, sometimes, the odds of always attending vs sometimes and rarely
and rarely attended were 81%, 12%, and 7%, respec- attending combined were 0.77 times lower, adjusted
tively. In contrast, of the participants with suboptimal for age, race, and sex (P 5 0.008). The Figure shows
oral hygiene practices, the proportions who reported the probability of the different attendance categories
they always, sometimes, and rarely attended were plotted over the treatment duration.
52%, 34%, and 14%, respectively. Those who practiced According to the logistic regression, the age cate-
brushing and flossing daily were more likely to attend gories were not significantly associated with attendance.
than were those who did not brush and floss daily Table III includes the probabilities of attending. Girls
(P 5 0.003; chi-square test). had a higher probability of attending than did boys (82%
Overall, there was no statistically significant differ- and 72%, respectively). All race categories had similar
ence in attendance history among the different race or attendance probabilities (range, 78%-83%) except for
ethnic categories (P 5 0.075; chi-square test) or among African Americans, who had a 68% probability of
the different age categories (P 5 0.309; chi-square test). attending appointments. Medicaid participants had
Moreover, there were no statistically significant associa- lower attendance probabilities than did non-Medicaid
tions between attendance history and the duration of participants (69% and 87%, respectively). The probabil-
active orthodontic treatment (P 5 0.322; ANOVA) or ity of attending appointments was higher among partic-
age of the participants (P 5 0.74; ANOVA). ipants who brushed daily than in those who did not (83%
The results of the multivariable analyses examining and 52%, respectively).
the simultaneous associations between attendance
(dependent variable) and insurance type, oral hygiene
behavior, and treatment duration are summarized DISCUSSION
in Table II. For non-Medicaid participants, the odds of In 2009, Lindauer et al14 conducted a study over a
always attending vs sometimes and rarely attending 6-week period where the last appointment of each
combined were 4 times higher than for Medicaid partic- active, non-Medicaid participant (n 5 538) was recorded
ipants, adjusted for age, race, and sex (P 5 0.018). as either kept or missed. They reported that male pa-
For participants with good oral hygiene (brush and tients were more likely to miss their orthodontic ap-
floss daily), the odds of always attending vs sometimes pointments. Moreover, Qui~ nonez et al15 found that
and rarely attending combined were almost 6 times boys attended fewer follow-up visits in a study in which
higher than for participants with suboptimal oral the parents of Medicaid children completed a question-
hygiene practices, adjusted for age, race, and sex naire before their child's medical visit. The providers
(P 5 0.002). completed patient dental forms at each visit, recording

March 2016
Vol 149
Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics
Bukhari, Sohrabi, and Tavares 323

These differences may be due to different Medicaid

Table III. Probability of attendance by participants'
participant proportions among the study populations:
characteristics
the sample of Lindauer et al consisted entirely of
Model 2: ordered non-Medicaid subjects, and the sample of Horsley et al
logistic regression was dominated by non-Medicaid patients (74%). In
Model 1: treating treating age
Characteristic age categorically continuously our study, Medicaid participants were more common
Age (\12 y) (61%).
Attendence probability 81% NA Our findings about the attendance behavior among
95% CI 61%-93% NA Medicaid participants were similar to those reported in
Age (12 to \16 y) previous studies.16,17 In our study, 24% (18.7%
Attendence probability 74% NA
95% CI 65%-84% NA
Medicaid and 5.3% non-Medicaid) of the patients re-
Age (.16 y) ported sometimes or rarely attending orthodontic ap-
Attendence probability 79% NA pointments; among those, 78% were Medicaid
95% CI 68%-90% NA insured. With elevated no-shows, it is clear why dentist
Male participation in Medicaid dental coverage is so low.
Attendence probability 73% 72%
95% CI 63%-82% 63%-82%
Lamberth et al18 specified that broken appointments
Female by Medicaid participants affect a dentist's decision
Attendence probability 82% 82% whether to participate in Medicaid insurance. Even
95% CI 72%-91% 73%-91% though low reimbursement is considered the principal
White restriction to accepting Medicaid patients, a missed
Attendence probability 82% 83%
95% CI 69%-96% 69%-96%
appointment generates no income. Additionally, a
African American missed appointment could have been used for another
Attendence probability 67% 68% patient.
95% CI 55%-80% 55%-80% In 1998, Breistein and Burden19 found that dental
Hispanic health was a significant predictor for receiving ortho-
Attendence probability 83% 82%
95% CI 72%-94% 70%-93%
dontic treatment: healthier patients (no caries and no
Other* oral hygiene problems) were more likely to receive ortho-
Attendence probability 78% 78% dontic treatment. We found that patients who practiced
95% CI 58%-98% 58%-98% good oral hygiene daily were more likely to attend ap-
Medicaid pointments, and this increases their chances to receive
Attendence probability 70% 69%
95% CI 60%-80% 59%-79%
and complete the orthodontic treatment.
Non-Medicaid Obviously, in any treatment plan, the longer the
Attendence probability 87% 87% treatment, the more likely it is for a patient to miss ap-
95% CI 78%-96% 78%-96% pointments. In our study, we found that active treatment
Brush daily (yes) duration was a significant predictor for patients'
Attendence probability 83% 83%
95% CI 76%-90% 76%-89%
attendance.
Brush daily (no) We could not perform ordered logistic regression
Attendence probability 50% 52% with a model that contained age as a categorical variable
95% CI 30%-69% 35%-70% (\12, 12 to \16, and .16 years) because of sample size
NA, Not applicable. issues when there were no participants in the category of
*Because of the small cell size, we used the exact method to estimate less than 12 years old who reported rare attendance.
the probability. However, to overcome this issue, we combined the
sometimes attendance group with the rarely attendance
group, and performed logistic regression with the binary
dental services, caries risk, and dental disease. Question- dependent variable (always attend vs sometimes or
naires, dental forms, and Medicaid claims were con- rarely) and categorical age as predictors. Although we
nected to generate a database. Although our bivariate did not find a significant difference in attendance be-
analysis results support these findings, the attendance tween the different age groups, we cannot be confident
by sex was not significantly different after adjusting that age is not a predictor for participants' attendance.
for age, race, oral hygiene, and insurance type through Conversely, the American Association of Orthodontists
an ordered logistic regression model. On the other Insurance Company stated that teenaged patients who
hand, Horsley et al16 reported that female patients drive to appointments and are less than passionate
were more likely to miss their orthodontic appointments. about their treatment often have irregular attendance.

American Journal of Orthodontics and Dentofacial Orthopedics March 2016
Vol 149
Issue 3
324 Bukhari, Sohrabi, and Tavares

More research should be conducted to answer this 3. Trenouth MJ. Do failed appointments lead to discontinuation of
question. orthodontic treatment? Angle Orthod 2003;73:51-5.
4. Richardson A. Failed appointments in an academic orthodontic
Additionally, to address whether the severity of
clinic. Br Dent J 1998;184:612-5.
malocclusion is associated with attendance, we adjusted 5. Can S, Macfarlane T, O'Brien KD. The use of postal reminders to
for Peer Assessment Rating scores, and it had no signif- reduce non-attendance at an orthodontic clinic: a randomised
icant effect. controlled trial. Br Dent J 2003;19:199-201.
One other limitation of our study about attendance 6. Haeger RS, Colberg RT. Effects of missed appointments and
bracket failures on treatment efficiency and office productivity.
history was that we relied on self-reported question-
J Clin Orthod 2007;41:433-7.
naires for attendance. The assessments of attendance 7. Fink DF, Smith RJ. The duration of orthodontic treatment. Am
and oral hygiene (with a question about brushing and J Orthod Dentofacial Orthop 1992;102:45-51.
flossing daily) might be more subjective. 8. Beckwith FR, Ackerman RJ Jr, Cobb CM, Tira DE. An evaluation of
factors affecting duration of orthodontic treatment. Am J Orthod
Dentofacial Orthop 1999;115:439-47.
CONCLUSIONS
9. Jarvinen S, Widstrom E, Raitio M. Factors affecting the duration of
There were significant associations between oral hy- orthodontic treatment in children. A retrospective study. Swed
giene practices (brush and floss daily), insurance type, Dent J 2004;28:93-100.
10. Marcusson A, Norevall LI, Persson M. White spot reduction
treatment duration, and probability of attendance. Our
when using glass ionomer cement for bonding in orthodontics:
findings support the concern among orthodontists that a longitudinal and comparative study. Eur J Orthod 1997;19:
Medicaid participants have higher no-shows than do 233-42.
non-Medicaid participants. Future research should focus 11. Trenouth MJ, Hough A. Reasons for broken and canceled appoint-
on exploring additional reasons that Medicaid patients ments in a British orthodontic clinic. J Clin Orthod 1991;25:
115-20.
have higher no-shows, and potentially develop and vali-
12. Reekie D, Devlin H. Preventing failed appointments in general
date new behavioral treatment priority settings (incor- dental practice: a comparison of reminder methods. Br Dent J
porating quality of life, oral hygiene, and compliance) 1998;185:472-4.
that can help to improve the current Medicaid screening 13. Bursac Z, Gauss CH, Williams DK, Hosmer DW. Purposeful selec-
systems that are based only on clinical or medical neces- tion of variables in logistic regression. Source Code Biol Med
2008;3:17.
sity, with a firm cutoff threshold. Furthermore, this can
14. Lindauer SJ, Powell JA, Leypoldt BC, T€
ufekçi E, Shroff B. Influence
help to identify patients who need more help with of patient financial account status on orthodontic appointment
compliance and eventually save orthodontic staff time attendance. Angle Orthod 2009;79:755-8.
and better allocate resources for Medicaid. 15. Qui~nonez RB, Pahel BT, Rozier RG, Stearns SC. Follow-up preven-
tive dental visits for Medicaid-enrolled children in the medical
office. J Public Health Dent 2008;68:131-8.
ACKNOWLEDGMENTS
16. Horsley BP, Lindauer SJ, Shroff B, T€ ufekçi E, Abubaker AO,
Fowler CE, et al. Appointment keeping behavior of Medicaid vs
We thank the dentists who provided access to non-Medicaid orthodontic patients. Am J Orthod Dentofacial Or-
their patients: Patricia Brown, Robert Petrosino, and thop 2007;132:49-53.
Mohamed Butt. 17. Brysh LS. “Where's my patient?”—a plan to decrease broken ap-
pointments in a predominantly Medicaid clinic. Spec Care Dentist
REFERENCES 2001;21:126-8.
18. Lamberth EF, Rothstein EP, Hipp TJ, Souder RL, Kennedy TI,
1. Asimakopoulou K, Daly B. Adherence in dental settings. Dent Up- Faccenda DF, et al. Rates of missed appointments among pediatric
date 2009;36:626-30. patients in a private practice: Medicaid compared with private
2. Franklin E. Missed appointments often result in malpractice insurance. Arch Pediatr Adolesc Med 2002;156:86-7.
claims. Available at: https://www.aaoinfo.org/news/2014/01/ 19. Breistein B, Burden DJ. Equity and orthodontic treatment: a study
missed-appointments-often-result-malpractice-claims. Accessed among adolescents in Northern Ireland. Am J Orthod Dentofacial
August 31, 2014. Orthop 1998;113:408-13.

March 2016
Vol 149
Issue 3 American Journal of Orthodontics and Dentofacial Orthopedics