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-
porting patients in changing their oral health
behaviors and maintaining those changes.1 Ac-
cording to the American Association of Orthodontists,
because orthodontic treatment is seldom finished
rapidly, the assumption would be that patients who
want good-looking smiles and healthier occlusions
would attend every appointment and comply with every
treatment instruction to accomplish the desired
outcome as rapidly as possible.2 In orthodontics,
a
Resident, Harvard School of Dental Medicine, Boston, Mass; lecturer, Faculty of
Dentistry, Umm Al-Qura University, Mecca, Saudi Arabia.
b
Resident, School of Dentistry, University of Washington, Seattle, Wash.
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.
All authors have completed and submitted the ICMJE Form for Disclosure of Po-
tential Conflicts of Interest, and none were reported.
Address correspondence to: Omair M. Bukhari, Harvard School of Dental Medi-
cine, Oral Health Policy and Epidemiology, REB 204, 188 Longwood Ave, Boston,
MA 02115; e-mail, omair_bukhari@hsdm.harvard.edu.
Submitted, April 2015; revised and accepted, July 2015.
0889-5406/$36.00
Copyright Ó 2016 by the American Association of Orthodontists.
http://dx.doi.org/10.1016/j.ajodo.2015.07.040
adherence means attending appointments, maintaining
good oral hygiene, wearing elastics or functional appli-
ances as instructed, and avoiding foods that can loosen
the brackets.
In 2003, Trenouth3 found that the failure rate of pa-
tients who completed orthodontic treatment was 10.3%,
and the failure rate of patients who discontinued ortho-
dontic treatment was 21.4%. Therefore, we could say
that attendance affected treatment success. In other
studies, “no-show” rates for orthodontic appointments
ranged from 13.6%4 to 23.3%.5 Patients who neglected
orthodontic appointments during active treatment were
likely to prolong their treatment durations6-9; as a result,
they might experience more harmful side effects.10
Missed appointments decrease the possibility that ortho-
dontic treatment will be completed successfully.3
The American Association of Orthodontists Insurance
Company suggests the following possible causes for a
patient's failure to keep orthodontic appointments:
teenaged patients who are less than passionate about
treatment; an unexpected illness or a crisis in the family;
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
the most critical and frequent cause, is that the patient
simply forgot.11,12 Forgetting indicates patient
behavioral attitudes and oral health literacy.
Although previous behavioral epidemiologic studies
have tried to establish a connection between a patient's
compliance with treatment, missed appointments, and
oral hygiene, we could not find a study performed in
private orthodontic offices in the United States.
Although it is commonly thought that there is a corre-
lation among elastic wear, showing up for appoint-
ments, and oral hygiene level, studies have shown
contradictory results. Moreover, because of a lack of
consensus about factors affecting attendance and the
high percentage of malpractice claims against ortho-
dontists who have frequent no-show patients, the
American Association of Orthodontists Insurance Com-
pany recommends paying close attention to patient
attendance deficiencies and addressing them as early
as possible. Therefore, in this study, we predicted that
attendance through a set of variables collected during
the first visit would help to predict possible future
attendance behavior, improve outcomes, and reduce
the percentage of malpractice claims associated with
no-show patients.
MATERIAL AND METHODS
The study population was orthodontic patients in the
Greater Boston area of Massachusetts. The participants
were recruited from 3 private orthodontic offices in Bos-
ton, Cambridge, and Somerville. One hundred fifty-three
participants were invited to participate in the study, and
none refused or was unable to complete the question-
naire because of literacy problems. The subjects included
81 girls (53%) and 72 boys (47%). Their mean age was
14.7 years (SD, 3.9 years), and the mean average treat-
ment time was 21 months (SD, 16 months). Demo-
graphics and participants' characteristics are shown in
Table I. Overall, there were 54 African Americans
(34.6%), 44 whites (28.8%), 41 Hispanics (27.6%), and
14 (9%) participants from other ethnic backgrounds.
Medicaid insurance was used by 93 of the participants
(60.9%). Patients with severe dentofacial deformities
were excluded. Parents' consents and children's assents
were obtained.
This was a convenience sample of patients who
agreed to take the surveys and signed the consent
form. The study was approved by Committee on Human
Studies of Harvard University Faculty of Medicine.
The participants completed self-administered ques-
tionnaires guided by a face-to-face interview. The ques-
tionnaire was divided into 8 parts: (1) demographic data,
(2) oral hygiene practices, (3) payment method, (4)
attendance history, (5) patients' and parents' percep-
tions about the importance of braces, (6) treatment
duration (actual time that the participant was undergo-
ing active orthodontic treatment), (7) Oral Impact on
Daily Performances scores, and (8) Peer Assessment Rat-
ing scores.

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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).

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Probabilities of different attendance categories
1
.8
Probability
.6
.4
.2
0
0 20
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,
the proportions who reported they always, sometimes,
and rarely attended were 81%, 12%, and 7%, respec-
tively. In contrast, of the participants with suboptimal
oral hygiene practices, the proportions who reported
they always, sometimes, and rarely attended were
52%, 34%, and 14%, respectively. Those who practiced
brushing and flossing daily were more likely to attend
than were those who did not brush and floss daily
(P 5 0.003; chi-square test).
Overall, there was no statistically significant differ-
ence in attendance history among the different race or
ethnic categories (P 5 0.075; chi-square test) or among
the different age categories (P 5 0.309; chi-square test).
Moreover, there were no statistically significant associa-
tions between attendance history and the duration of
active orthodontic treatment (P 5 0.322; ANOVA) or
age of the participants (P 5 0.74; ANOVA).
The results of the multivariable analyses examining
the simultaneous associations between attendance
(dependent variable) and insurance type, oral hygiene
behavior, and treatment duration are summarized
in Table II. For non-Medicaid participants, the odds of
always attending vs sometimes and rarely attending
combined were 4 times higher than for Medicaid partic-
ipants, adjusted for age, race, and sex (P 5 0.018).
For participants with good oral hygiene (brush and
floss daily), the odds of always attending vs sometimes
and rarely attending combined were almost 6 times
higher than for participants with suboptimal oral
hygiene practices, adjusted for age, race, and sex
(P 5 0.002).
March 2016
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Bukhari, Sohrabi, and Tavares
probability of A
probability of S
probability of R
40 60 80
For every 6-month increase in treatment duration,
the odds of always attending vs sometimes and rarely
attending combined were 0.77 times lower, adjusted
for age, race, and sex (P 5 0.008). The Figure shows
the probability of the different attendance categories
plotted over the treatment duration.
According to the logistic regression, the age cate-
gories were not significantly associated with attendance.
Table III includes the probabilities of attending. Girls
had a higher probability of attending than did boys (82%
and 72%, respectively). All race categories had similar
attendance probabilities (range, 78%-83%) except for
African Americans, who had a 68% probability of
attending appointments. Medicaid participants had
lower attendance probabilities than did non-Medicaid
participants (69% and 87%, respectively). The probabil-
ity of attending appointments was higher among partic-
ipants who brushed daily than in those who did not (83%
and 52%, respectively).
DISCUSSION
In 2009, Lindauer et al14 conducted a study over a
6-week period where the last appointment of each
active, non-Medicaid participant (n 5 538) was recorded
as either kept or missed. They reported that male pa-
tients were more likely to miss their orthodontic ap-
pointments. Moreover, Qui~ nonez et al15 found that
boys attended fewer follow-up visits in a study in which
the parents of Medicaid children completed a question-
naire before their child's medical visit. The providers
completed patient dental forms at each visit, recording
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.

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More research should be conducted to answer this
question.
Additionally, to address whether the severity of
malocclusion is associated with attendance, we adjusted
for Peer Assessment Rating scores, and it had no signif-
icant effect.
One other limitation of our study about attendance
history was that we relied on self-reported question-
naires for attendance. The assessments of attendance
and oral hygiene (with a question about brushing and
flossing daily) might be more subjective.
CONCLUSIONS
There were significant associations between oral hy-
giene practices (brush and floss daily), insurance type,
treatment duration, and probability of attendance. Our
findings support the concern among orthodontists that
Medicaid participants have higher no-shows than do
non-Medicaid participants. Future research should focus
on exploring additional reasons that Medicaid patients
have higher no-shows, and potentially develop and vali-
date new behavioral treatment priority settings (incor-
porating quality of life, oral hygiene, and compliance)
that can help to improve the current Medicaid screening
systems that are based only on clinical or medical neces-
sity, with a firm cutoff threshold. Furthermore, this can
help to identify patients who need more help with
compliance and eventually save orthodontic staff time
and better allocate resources for Medicaid.
ACKNOWLEDGMENTS
We thank the dentists who provided access to
their patients: Patricia Brown, Robert Petrosino, and
Mohamed Butt.
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