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.