Factors affecting orthodontists management of the retention phase

Originl Article Fctors ffecting orthodontists mngement of the retention phse Kevin Bibon ; Bhvn Shroff b ; Al M. Best c ; Steven J. Linduer d ABSTRACT Objective: To test the null hypothesis tht orthodontist chrcteristics nd fctors relted to retiner choice do not influence the mngement of the retention phse with regrd to frequency nd durtion of follow-up cre provided. Mterils nd Methods: Orthodontists (n 5 1000) were rndomly selected to prticipte in n online survey divided into three ctegories: bckground, retiner choice, nd time mngement. Results: Of the 1000 selected prticipnts, 894 responded. When deciding the type of retiner to use, the following were considered most frequently: pretretment mlocclusion (91%), ptient complince (87%), ptient orl hygiene (84%), nd ptients desires (81%). Orthodontists who considered the presence of third molrs (P 5.03) or specil needs ptients (P 5.02) hd significntly more follow-up visits thn those who did not. When vcuum-formed retiners (VFRs) were prescribed, there were significntly fewer visits (P 5.02) compred to when other types of retiners were used. As prctitioner experience incresed, so did the number of visits (P,.0001). Orthodontists who considered the primry responsibility of retention to fll on the ptient hd significntly fewer follow-up visits (P,.0001) thn those who considered it either joint or orthodontist-only responsibility. Conclusions: The null hypothesis ws rejected becuse the number of follow-up visits during the retention phse ws ffected by prctitioner experience, whether VFRs were used, whether the orthodontist considered the presence of third molrs or specil-needs ptients when choosing the type of retiner, nd to whom the orthodontist ttributed responsibility during the retention phse. (Angle Orthod. 2014;84:225 230.) KEY WORDS: Orthodontist; Retention; Mngement INTRODUCTION Retention is necessry therpeutic phse following ctive orthodontic tretment, with the gol of mintining the obtined intr-rch lignment nd interrch reltionships. After the conclusion of ctive tretment, mny physiologicl forces cn move teeth Resident, Deprtment of Orthodontics, Virgini Commonwelth University, Richmond, V. b Professor nd Grdute Progrm Director, Deprtment of Orthodontics, Virgini Commonwelth University, Richmond, V. c Professor, Deprtment of Biosttistics, School of Dentistry, Virgini Commonwelth University, Richmond, V. d Professor nd Chir, Deprtment of Orthodontics, Virgini Commonwelth University, Richmond, V. Corresponding uthor: Dr Bhvn Shroff, Deprtment of Orthodontics, VCU School of Dentistry, 520 North 12th St, Suite 111, Richmond, VA 23298 (e-mil: bshroff@vcu.edu) Accepted: July 2013. Submitted: My 2013. Published Online: August 14, 2013 G 2014 by The EH Angle Eduction nd Reserch Foundtion, Inc. bck to their originl positions, including suprcrestl nd gingivl PDL fibers, eruptive forces, nd deleterious hbits developed by ptients. 1,2 Therefore, some type of retention is thought to be required indefinitely to prevent relpse. 2 Becuse of the importnce of retention, systemtic orgniztion of the retention phse, including choice of retiner nd time mngement, is essentil to the success of both the orthodontic tretment nd the orthodontic prctice. Mny fctors should be considered when deciding wht type of retiner to give ech ptient. 2 4 Orthodontists in the Netherlnds consider the following fctors in descending order of frequency: pretretment sitution, interdigittion fter tretment, orl hygiene, end result, periodontl tissue, ptient motivtion, nd ptient ge. 4 Studies in the United Sttes hve been limited to determining the frequency with which retiners re used nd compring types of retiners to ech other. 5 12 Keim et l. 5 found tht the use of the Hwley retiner hs recently decresed while the use of cler retiners nd bonded retiners hs incresed. Vlithn nd Hughes 13 showed tht the Hwley DOI: 10.2319/051313-372.1 225

226 BIBONA, SHROFF, BEST, LINDAUER Figure 1. Brekdown of the number of yers in prctice of the survey prticipnts. retiner is the most common retiner used in the mxillry dentition, wheres fixed lingul retiner is the most common retiner used in the mndibulr dentition. Essix retiners hve been shown to be eqully s effective in preventing relpse, more costeffective, nd more preferred by ptients when compred to Hwley retiners. 6,14 According to Hughes et l., 15 businesses tht thrive in competitive environment hve defined nd effective strtegies for clinicl prctice. More specificlly, n efficient, successful orthodontic prctice is one tht cpitlizes on high number of ctive cses nd minimizes overhed. 16 Becuse the retention phse often involves four ppointments over 2-yer period, 5 missed ppointments my impct the clinicl efficiency of the orthodontic prctice. Schulmn nd McGill 17 found tht ptients re three times more likely to miss n ppointment during retention thn during ctive tretment. Therefore, it is criticl tht orthodontists hve protocol for ptient visits during the retention phse. Despite the inherent importnce of retention, how orthodontists choose the type of retiner to use for ech ptient nd how this choice ffects the retention recll schedule hve not been exmined. The gol of this study ws to test the null hypothesis tht there is no influence of orthodontist chrcteristics nd fctors relted to retiner choice on the mngement of the retention phse with regrd to frequency nd durtion of follow-up cre provided. MATERIALS AND METHODS A Web-bsed survey ws developed to exmine how orthodontists mnge the retention phse. Questions sked bout prticipnt demogrphics, the types of retiners used, how the choice of retiner ws mde for ech ptient, nd how frequently nd for how long prticipnts scheduled ppointments. Following pprovl by the Institutionl Review Bord of Virgini Figure 2. Brekdown of the ge in yers of the survey prticipnts. Commonwelth University, the Americn Assocition of Orthodontists rndomly selected 1000 orthodontists throughout the United Sttes to receive the survey. The online link to the survey ws then sent vi e-mil to those selected, with follow-up e-mil sent 4 weeks lter in n effort to increse prticiption. The results were collected nd summry descriptive sttistics were clculted. In order to determine the vribles tht were ssocited with the durtion or frequency of the retention phse, univrite nlyses (nlysis of vrince or correltion, s indicted) were performed using SAS softwre (JMP 9.0.2; SAS Institute Inc, Cry, NC). RESULTS The survey ws sent to 1000 orthodontists nd hd return rte of 89.4% (n 5 894). The demogrphic chrcteristics of the prticipnts in the survey re shown in Figures 1 nd 2. While the mle-to-femle rtio of prticipnts ws 4:1, the number of yers in prctice of ech prticipnt ws evenly distributed between 0 nd.35 yers. Since ge, number of yers in prctice, nd yer of grdution from orthodontic residency were highly correlted ( r..92), prctitioner experience will be described by yer of grdution from orthodontic residency. Retiner Choice When sked if there should be stndrd of cre regrding retention procedures nd pplinces, 56% of prticipnts responded Yes, nd 44% responded No. When determining the type of retiner to use, 54% of the respondents indicted tht they do so t the end of tretment, while 43% decided during initil tretment plnning, nd 3% decided during tretment. Over 81% of respondents stted they use bonded, Hwley, nd vcuum-formed retiners (VFRs) in their prctice. The frequency of vrious fctors considered tht pertin to retiner choice nd prescription re shown in Figure 3.

ORTHODONTISTS MANAGEMENT OF THE RETENTION PHASE 227 Figure 3. Frequency of fctors considered by orthodontists when choosing the type of retiner. Pretretment mlocclusion, complince, orl hygiene, nd the ptient s desires were considered by more thn 80% of prticipnts, wheres the presence of third molrs, gender, nd insurnce were ech considered by less thn 10% of prticipnts. Though not sttisticlly significnt, ptient desires were considered less frequently s prctitioner experience incresed. The prticipnts discussed the choice of retiner 3% of the time with the ptient s dentist compred to 41% of the time with the ptient s periodontist, when pplicble. For those respondents who prescribed removble retiners, 52.3% prescribed them to be worn on prttime bsis. Of this group, 99.6% sked the ptients to wer the retiner only t night, s opposed to during the dy only or every other dy. Time Mngement Over 90% of orthodontists sw their ptients for 15 minutes or less t ech ppointment. Figure 4 shows the frequency of ppointments nd durtion of follow-up cre during the retention phse. Follow-up cre for #12 months ws offered by 28% of orthodontists. For these orthodontists, the frequency of visits ws predominntly qurterly (74%). This is in contrst to the orthodontists who offered follow-up for 13 24 months (42%) or more thn 24 months (31%), with frequency of visits being predominntly seminnul (56% nd 55%, respectively). Yerly visits were rre (less thn 6%). For ll of the following results, the number of follow-up visits ws clculted by combining frequency of visits nd durtion of retention phse, s shown by the numbers top ech br in Figure 4. The presence of third molrs nd whether the ptients were specil needs were the only fctors considered when choosing the type of retiner tht hd significnt impct on the number of follow-up visits (Tble 1). Orthodontists who considered the presence of third molrs hd significntly more follow-up visits Figure 4. Durtion nd frequency of follow-up cre offered during the retention phse. The height of the brs is proportionl to the number of orthodontists chosing ech combintion of frequency of visits nd durtion of retention phse. The number top ech br is the totl number of visits clculted for ech combintion. thn those who did not (men 5 5.4 visits vs 4.8 visits; P 5.03). Orthodontists who considered specil needs hd significntly more follow-up visits thn those who did not (men 5 5.1 versus 4.7; P 5.02). The type of retiner chosen ws unrelted to the number of follow-up visits (P..08) except for orthodontists who used VFR (Tble 2). For orthodontists who used VFR, the verge number of visits ws eight, compred to five for orthodontists who did not use VFR (P 5.02). Full- versus prt-time removble retiner use ws not relted to the number of follow-up visits (P..07). As prctitioner experience incresed, so did the number of prescribed retention visits (P,.0001; Tble 3). Those who grduted prior to 1980 verged 5.4 visits, which ws significntly greter thn the verge number of visits (4.5) for those who grduted s recently s 1990. Slightly more thn hlf (51%) of the surveyed orthodontists considered retention s joint responsibility between the orthodontist nd the ptient, while 47% considered the responsibility to fll on the ptient, nd less thn 3% considered the responsibility to fll solely on the orthodontist. Orthodontists who considered the primry responsibility of retention to fll on the ptient hd significntly fewer (P,.0001) follow-up visits thn those who considered it either joint or orthodontist-only responsibility (men 5 4.5 vs 5.2, respectively). Of those who grduted prior to 1990 nd viewed retention s fully or prtilly their own responsibility, 44% recommended more thn 2-yer follow-up period. Of the recent grdutes (1990 nd fter) who viewed retention s fully or prtilly their

228 BIBONA, SHROFF, BEST, LINDAUER Tble 1. Number of Follow-up Visits vs Fctors Considered When Choosing the Type of Retiner Fctor Considered Percentge (n) Men SD P Vlue Pretretment mlocclusion Yes 90.4 (808) 4.85 2.24.8663 No 9.6 (86) 4.90 2.58 Complince Yes 86.2 (771) 4.89 2.30.2356 No 13.8 (123) 4.63 2.16 Orl hygiene Yes 83.3 (745) 4.89 2.30.2737 No 16.7 (149) 4.67 2.17 Ptient s desires Yes 80.4 (719) 4.84 2.31.7576 No 19.6 (175) 4.90 2.16 Posttretment occlusion Yes 69.6 (622) 4.94 2.33.0773 No 30.4 (272) 4.65 2.14 Age Yes 65.4 (585) 4.94 2.31.1039 No 34.6 (309) 4.68 2.21 Specil-needs ptients Yes 48.3 (432) 5.05 2.37.0114 No 51.7 (462) 4.66 2.18 Fmily sitution Yes 16.4 (147) 4.92 2.57.7238 No 83.6 (747) 4.84 2.22 Presence of 3rd molrs Yes 8.7 (78) 5.41 2.82.0232 No 91.3 (816) 4.80 2.21 Sex Yes 8.1 (72) 4.93 1.94.7225 No 91.9 (822) 4.84 2.31 Other Yes 6.4 (57) 5.11 2.32.3955 No 93.6 (837) 4.83 2.28 Insurnce Yes 0.7 (6) 4.50 1.76.6450 No 99.3 (888) 4.85 2.28 SD indictes stndrd devition. own responsibility, 28% recommended more thn 2- yer follow-up period. DISCUSSION Number of Visits The null hypothesis ws rejected becuse the frequency nd durtion of follow-up visits during the retention phse ws ffected by prctitioner experience, whether VFRs were used, whether the orthodontist considered the presence of third molrs or specil-needs ptients when choosing the type of retiner, nd to whom the orthodontist ttributed responsibility during the retention phse. Tble 2. Number of Follow-up Visits vs Type of Retiner Used Number of Visits Type Percentge (n) Men SD P Vlue Bonded Yes 93.7 (837) 4.83 2.25.2436 No 6.3 (56) 5.25 2.62 Hwley Yes 93.5 (835) 4.85 2.28.8267 No 6.5 (58) 4.83 2.31 Essix Yes 91.0 (813) 4.79 2.20.0204 No 9.0 (80) 5.46 2.89 Other Yes 16.1 (144) 5.15 2.26.0859 No 83.9 (749) 4.79 2.28 SD indictes stndrd devition. Orthodontists rrely considered the presence of third molrs when deciding wht type of retiner to prescribe. However, despite evidence tht the presence or bsence of third molrs does not impct lignment of incisors following retention, 18 orthodontists who did consider the presence of third molrs hd significntly more follow-up visits (P 5.03) during the retention phse thn those who did not. This increse in visits my hve been in prt due to ptient concerns nd the generl perception tht third molrs cuse nterior crowding, even without supporting scientific evidence. Although orthodontists considered whether the ptients were specil needs only 48% of the time when deciding wht type of retiner to prescribe, those tht did hd significntly more follow-up visits thn those who did not (men 5 5.1 versus 4.7; P 5.02). Specil-needs ptients re often more chllenging to tret due to behviorl issues, 19 so it ws not surprising tht orthodontists wnted to see these ptients more often to ensure tht the finl results of tretment were mintined. When VFR ws prescribed, there ws significntly smller verge number of visits compred to when other retiners were prescribed (P 5.02). These findings were consistent with those from the study of Vlithn nd Hughes 13 tht showed retention ppointments were scheduled t longer time intervls when orthodontists prescribed VFRs. VFRs hve been shown to hve smller increses in the Irregulrity Index nd smller decreses in PAR (peer ssessment rting) scores six months following debonding. 20 Therefore, it is resonble to ssume tht when orthodontists prescribed VFRs, they were less worried bout the relpse thn they would hve been hd they prescribed other retiners. However, becuse ptient complince with VFRs hs been shown to decrese

ORTHODONTISTS MANAGEMENT OF THE RETENTION PHASE 229 Tble 3. Number of Follow-up Visits vs Yer of Grdution From Orthodontic Residency Men, y Number of Visits Grdution Decde n Percentge Age Prctice Men SD * 1950s nd 1960s 31 3.5 70.0 36.8 5.90 3.49 (b) 1970s 162 18.5 65.1 35.0 5.30 2.64 (b) 1980s 224 25.6 56.1 25.3 5.01 2.16 (b)(c) 1990s 216 24.7 46.7 15.7 4.50 2.06 (c) 2000 to present 242 27.7 36.8 5.1 4.58 2.04 (c) SD indictes stndrd devition. * Averge numbers of visits significntly different (ANOVA P 5.0001). Mens with only (b) re significntly different thn mens with only (c). Mens with both (b) nd (c) re not significntly different from the mens tht hve only (b) or (c) (Tukey Honestly Significnt Difference). more rpidly 2 yers fter debonding thn with Hwley retiners, it would be prudent to monitor ptients who receive VFRs for more thn 2 yers. 21 Overll, most orthodontists verged the sme number of visits (pproximtely four) for the ptients during the retention phse, indicting tht orthodontists plced similr importnce on retention. However, the distribution of the visits vried gretly. For those orthodontists who sw ptients for #12 months, the ptients were typiclly seen qurterly, thus verging four visits. For those orthodontists who sw ptients for 12 24 months, the ptients were typiclly seen semi-nnully, lso verging four visits. However, when exmining orthodontists with regrd to experience level, the number of visits significntly incresed (P,.0001) s prctitioner experience incresed. These results were similr to the findings of Vlithn nd Hughes 13 tht orthodontists with less thn 16 yers of experience scheduled retention ppointments less frequently. More experienced prctitioners might hve been more dubious of ptient complince over the long term, hving seen more cses of relpse over the length of their creer. Furthermore, when exmining orthodontists with regrd to their belief s to who bers responsibility during the retention phse, those who believed tht the ptient bers sole responsibility hd significntly fewer visits (P,.0001). The number of visits incresed s orthodontists perception of their own responsibility incresed. Orthodontists who considered retention joint or orthodontist-only responsibility probbly wnted to keep closer wtch on their ptients thn those who believed otherwise. CONCLUSIONS N The number of follow-up visits incresed if the orthodontists considered the presence of third molrs or specil needs ptients when deciding the type of retiner to use. N The number of follow-up visits incresed s prctitioner experience incresed. N The number of follow-up visits decresed when VFR ws used nd when orthodontists considered the primry responsibility for retention to fll on the ptient. ACKNOWLEDGMENTS This study ws supported in prt by the AD Willims Student Reserch Fellowship nd by the Medicl College of Virgini Orthodontic Eduction nd Reserch Foundtion. REFERENCES 1. Reitn K. Principles of retention nd voidnce of posttretment relpse. Am J Orthod. 1969;55:776 790. 2. Wytt WE. Retention: long nd constnt contrct. J Gen Orthod. 1998;9:23 27. 3. Wytt WE. Retention: long nd constnt contrct (prt II). J Gen Orthod. 1999;10:9 12. 4. Renkem AM, Sips ET, Bronkhorst E, Kuijpers-Jgtmn AM. A survey on orthodontic retention procedures in The Netherlnds. Eur J Orthod. 2009;31:432 437. 5. Keim RG, Gottlieb EL, Nelson AH, Vogels DS III. 2008 JCO study of orthodontic dignosis nd tretment procedures, prt 1: results nd trends. J Clin Orthod. 2008;42:625 640. 6. Linduer SJ, Shoff RC. Comprison of Essix nd Hwley retiners. J Clin Orthod. 1998;32:95 97. 7. Wong P, Freer TJ. Ptients ttitudes towrds complince with retiner wer. Aust Orthod J. 2005;21:45 53. 8. Booth FA, Edelmn JM, Proffit WR. Twenty-yer follow-up of ptients with permnently bonded mndibulr cnine-tocnine retiners. Am J Orthod Dentofcil Orthop. 2008; 133:70 76. 9. Renkem AM, Al-Assd S, Bronkhorst E, Weindel S, Ktsros C, Lisson JA. Effectiveness of lingul retiners bonded to the cnines in preventing mndibulr incisor relpse. Am J Orthod Dentofcil Orthop. 2008;134: 179e1 8. 10. Ktsros C, Livs C, Renkem AM. Unexpected complictions of bonded mndibulr lingul retiners. Am J Orthod Dentofcil Orthop. 2007;132:838 841. 11. Levin L, Smorodnitzky-Nveh GR, Mchtei EE. The ssocition of orthodontic tretment nd fixed retiners with gingivl helth. J Periodontol. 2008;79:2087 2092. 12. Pndis N, Vlhopoulos K, Mdinos P, Elides T. Long-term periodontl sttus of ptients with mndibulr lingul fixed retention. Eur J Orthod. 2007;29:471 476. 13. Vlithn M, Hughes E. Results of survey-bsed study to identify common retention prctices in the United Sttes. Am J Orthod Dentofcil Orthop. 2013;137:170 177.

230 BIBONA, SHROFF, BEST, LINDAUER 14. Hichens L, Rowlnd H, Willims A, et l. Cost-effectiveness nd ptient stisfction: Hwley nd vcuum-formed retiners. Eur J Orthod. 2007;29:372 378. 15. Hughes D, Lndy M, Strj S, Tuncy O. Appliction of clssicl model of competitive business strtegy to orthodontic prctice. Am J Orthod Dentofcil Orthop. 1996;110: 405 409. 16. Gottlieb EL, Nelson AH, Vogels DS III. 2001 JCO orthodontic prctice study. Prt 2: prctice success. J Clin Orthod. 2001;35:673 681. 17. Schulmn ML, McGill JK. How does your orthodontic prctice stck up? J Clin Orthod. 2002;36:281 283. 18. Ades AG, Joondeph DR, Little RM, Chpko MK. A long-term study of the reltionship of third molrs to chnges in the mndibulr dentl rch. Am J Orthod Dentofcil Orthop. 1990;97:323 335. 19. Becker A, Shpir J, Chushu S. Orthodontic tretment for the specil needs child. Prog Orthod. 2009;10:34 47. 20. Kumr AG, Bnsl A. Effectiveness nd cceptbility of Essix nd Begg retiners: prospective study. Aust Orthod J. 2011;27:52 56. 21. Prtt MC, Kluemper GT, Lindstrom AF. Ptient complince with orthodontic retiners in the postretention phse. Am J Orthod Dentofcil Orthop. 2011;140:196 201.